NIPER - Joint Entrance Examination 2011 FirstName* Middle Name LastName* Father's/Husband'sName* DOB* Address1* Address2* Address3* City*

State* PinCode* Category* ChoiceofExamCenter* Applyingas* Sex* MaritalStatus* Nationality* QualifyingDegree* StatusofQualifyingDegree* Qualifiedin* GPAT/GATEPercentage/Score* DDNumber* BankName* DDDate* DD Amount (Rs.)* Phone/MobileNo:withSTDcode* EmailID* singh Ram ji singh 10 36-H Pocket-A3 Mayur Vihar Phase-III New Delhi Delhi Delhi 110096 GEN Delhi Not Applicable Male UnMarried Indian B Pharm Passed GPAT & GATE 24.67 869672 Bank Of Baroda 10 1000 09551139277 ambrishagastya@gmail.com Jun 2011 Feb 1986 Ambrish

Nameandaddressofthecollegefromwherepursuing/pursuedqualifyingdegree* Rajiv Academy for Pharmacy, Mathura, N.H# 2, P.O Chhatikara,Mathura, U.P 281001

NameandAddressoftheUniversitytowhichcollegeisaffiliated* U.P.Technical University, Lucknow

Please take print out of the Registration slip and attach following:i) A non refundable Demand Draft of Rs.1000/-(Rs.500/- for SC/ST) payable at S.A.S. Nagar (Mohali)/Chandigarh in favour of NIPER JEE2011. For Foreigner, Demand Draft of US $100 to be paid. ii) Copy of the award letter (if any) pertaining to GATE/GPAT/NET etc. iii) Sponsorship certificate from industry/government sponsored candidates (format given at Annexure-2 in information brochure). and send it by speed post/registered post to Organizing Chairperson NIPER JEE 2011, Sector 67, S.A.S. Nagar (Mohali) Punjab 160062. UNDERTAKING:I hereby undertake that the information provided above is correct to the best of my knowledge and belief. I understand that in case any information provided here is provide to be false, my candidature is liable to be rejected. I also understand the following: a) That in the event of my failure to produce necessary documents (including proof in support of having passed the "qualifying degree exam with requisite percentage / CGPA and having valid GPAT/GATE/NET") at the time of counseling / GD & Interview, my candidature is liable to be rejected. b) That I will have to make claim for any kind of reservation / relaxation in percentage of marks / CGPA in qualifying degree by clearly mentioning the category that I belong to and that I am claiming. Failure to do so on my part shall make me ineligible for any such reservation / relaxation. c) As indicated in para 9.2 of the Information Brochure the admission to the Entrance Examination is merely provisional. Final consideration of the candidature is subject to fulfillment of eligibility criteria to be verified at the time of counseling and/or GD & interview. Date : __________________ Place : ___________________

____________________________________ Signature of the Applicant

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