TM OLYMPIAD Workshop [Session 2014-15] APPLICATION FORM Course Code 4069 Dates 4th May 2014 to 18th May 2014 Form No. For office use only Duration 15 Days Please Fill Center Name Target (Please Tick (P) Any One) Class Class VI NSO, IMO & NSTSE Class VII NSO, IMO, NSTSE & ANCQ Class VIII NSO, IMO, NSTSE, ANCQ & FOUNDATION OF JSO Class IX NSO, IMO, NSTSE & ANCQ Class X NTSE, NSO, IMO, NSTSE & ANCQ JSO RMO IBO NOTE : Workshop for JSO/RMO/IBO is available at AHMEDABAD Center ONLY. Name : ______________________________________________ Father's Name : ______________________________________________ Mother's Name : ______________________________________________ Date of Birth : Category : Father's Occupation : Gender Passport Size Colour Photograph here (dd/mm/yyyy) (GEN/SC/ST/OBC/OTHERS) Affix Your Recent (M/F) ______________________________________________________________ Address for Correspondence : ______________________________________________________________ _______________________________________City____________________ PIN _________________________State______________________________ Landline No (with STD code) Mobile No.1: :___________________ E-mail Id: ___________________________________ __________________________ Are you a CCP/DLP/ELP student of ALLEN ? Yes Mobile No.2: No. If yes _____________________________ ALLEN Form No. Scholarship Eligibility : 1. Scholarship# Category S.No. Advance Batch Students of Classroom Programme of Session 2014-15 Tick (if applicable) 100% 2. HBCSE Olympiad Stage-1 qualified students 75% 3. Students of Distance Learning Programme of Session 2013-14 50% Proof required Mention ALLEN Form No. HBCSE Stage 1 Qualification Certificate Mention ALLEN Form No. # Kindly attach relevant proof with application form in case you are eligible for any of the scholarship criteria. # No two scholarship criteria can be clubbed. Fee Details: Demand Draft Date Demand Draft No. Bank Name Amount *No refund in fee is applicable for workshop, under any circumstances. Accomodation required (Yes/No) : ____________ DECLARATION I hereby declare 1. That I shall be fully responsible for any accident/mishappening may be occurring with me inside/outside the institute premises. 2. That I will be responsible for my rustication on ground of my misconduct, misuse of mobile phone, or any illegal and indecent activity. 3. That in case of my selection in any exam, the institute reserves the right to utilise my information in the name of the Institute. 4. That I solemnly affirm that the institute has the right to send my emails (e-newsletters) and SMS alerts. 5. That all information furnished by me as in Application Form etc. is correct to the best of my knowledge. I understand that in the event of any information found to be incorrect or false, my admission may be cancelled without any refund fee. 6. That I am seeking admission in my own interest and accord. Signature (Father/Mother) Signature (Student) Date : ________________ Date : ________________