APPLICATION NUMBER 2194331 PAYMENT MODE CREDIT CARDCOURSE GROUP 1 AMOUNT 1600COURESES/APPLIED [BPharm/PharmD] DD NUMBER NATEST CENTER Delhi,Lucknow DD DATE NADATE OF BIRTH 14/9/1996 CATEGORY GENERALSEX Male NATIONALITY IndiaNAME OF THE APPLICANT Binu NairNAME OF THE PARENT/GUARDIAN

Omanakuttan PK

ADDRESS LINE 1 10 Old Idgah ColonyADDRESS LINE 2 NAADDRESS LINE 3 NAPIN 282001 STD CODE/TELEPHONE

NUMBERSNA

CITY Agra E-MAIL ADDRESS computerscreative@gmail.com

STATE Uttar Pradesh MOBILE NUMBER +919412651745DATE OF COMPLETION OFINTERNSHIP

NA

FOR MD/MSAPPLICANTS

FOR MTECHAPPLICANTS

ARE YOU A DIPLOMAHOLDER?

NA ARE YOU A GATE SCORER? NO

DECLARATIONS:I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. Ihave read and understood all provisions of admissions and agree to abide by them. I also affirm that I fulfil the eligibilityrequirements for the course/s applied. In the event of submission of fraudulent, incorrect or untrue information orsuppression or distortion of any fact, like educational qualification, marks, nationality etc. I understand that my admission/degree is liable for cancellation. I further understand that my admission is purely provisional subject to the verification of theeligibility conditions.NOTE:1.Please keep a copy of the filled in application for future reference.2.Application number must be quoted in all future correspondence.3.The candidates who are appearing for GATE exam should submit the valid score card on or before the lastdate of receipt of application (For MTech / MSc Tech applicants only)4.Please send this completed application form with DD/Challan(if payment is not via Credit Card) to: Director -Admissions, Manipal University, Manipal - 576104