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    Name in Full (As per SSC / X Certificates):

    Gender:         MaleFemale
    Nationality:
    Date of Birth:
    Place of Birth:
    State:
    Country:
    Mother's Name:
    Father/Husband's Name:
    Current Address:

    PIN:

    City:

    State:

    Country:

    Permanent Address same as above?

    Permanent Address:

    PIN:

    City:

    State:

    Country:

    Phone No. with STD Code:
    Mobile No.:
    Applicant's E-mail:
    Applying for Center at:
    Examination Examination Authority Year Marks/Grade Obtained Max. Marks Awaited/Passed
    X Min. Qualification for registration
    XII


    Place:
    I hereby declare that the information furnished herein above is true to the best of my knowledge.