APPLICATION FORM - 2013

Stream SX

Application No.

Name of Candidate (as in 10th Marks Card) : Parth JaiminiDate of Birth (dd/mm/yyyy) : 21/07/1996Category : GeneralPerson With Disability (PWD) : NoNationality : IndianGender : MaleX Board Registration Number : ASE120360700295

Exam Board Science Maths % of marks in Aggregate in

Science subjects &Mathematics

X Std(% marks)

CBSE 96 96 96

X Std Board (if others):In the academic year 2013-14 I have joined: XII Standard in Science Subjects Centre for writing Aptitude Test : JaipurLanguage in which would like to take your Aptitude Test : English Name of College/Institution : Maheshwari Public SchoolAddress of College/Institution : Sector-4,

Jawahar Nagar,Jaipur302004Rajasthan

Declaration by the student

I declare that the information provided above are true to the best of my knowledge and belief. I understandthat if it is found that I do not meet the eligibility norms at any point of time I may face disqualification fromthe KVPY program.

928,Barket Nagar,Tonk Phatak, Kisan Marg,JaipurRajasthan30201501412590567parthbluff.1990@gmail.com

Candidate Signature:

CERTIFIED BY THE COLLEGE/INSTITUTION

Mr. Parth Jaimini is a bonafide student of Maheshwari Public School and his

date of joining XII Standard in Science Subjects is on:

KVPY - Online Application http://www.kvpy.org.in/kvpy-1314/preview.php

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and all the information furnished by the applicant is correct.

Date:

Place:

Signature of the Head of the Institution

Name:

Institution Seal:

Your application for "Stream SX" has now been incorporated into our system and you have been assigned the

Application number .

However, your application is not complete until you do the following:

Take a print out of this Application Form and make sure that it is complete with a number.1.Please also obtain your School / College Principal’s signature and seal in the appropriate place.2.Do not make any changes / alterations to this page.3.Application Fee: An application fee of Rs. 500/- may be remitted to any core banking branch of“STATE BANK OF INDIA, to the credit of “Kishore Vaigyanik Protsahan Yojana (KVPY) A/c. No.10270577392”

» Download the challan/pay-in slip in .pdf format(http://www.kvpy.org.in/kvpy-1314/downloads/pay-in-slip.pdf)or» Download the challan/pay-in slip in .doc format(http://www.kvpy.org.in/kvpy-1314/downloads/pay-in-slip.doc)

The application fee is exempted for the following category of students:Students belonging to SC/ST.1.Physically and Visually challenged students (Person With Disability - PWD)2.

4.

The completed application form along with the following documents super scribing on the envelop thestream applied for, should reach the KVPY office on or before 2/09/13:

Caste certificate issued by the competent authority in the prescribed proforma in the case ofSC/ST students.Medical certificate from the prescribed authority in case of physically and visually challengedstudents certifying the percentage of disability.Copy of the marks statement of the qualifying examinations(s).Original Pay-In-Slip of the Application fee of Rs. 500/- (if applicable).

5.

Send all the above documents through Speed Post or Registered Post, toThe Convener, KVPYIndian Institute of ScienceBangalore – 560 012

6.

KVPY will not be responsible for postal delays in receiving the completed application form.7.You may check to see that your application is complete and all documents received at the KVPY office byvisiting to http://www.kvpy.org.in/ after two weeks of the posting of your application.

8.

Issue of hall ticket – through KVPY website (for online applicants only):Website URL: http://www.kvpy.org.in/Login ID – Application numberPassword – Date of Birth

9.

Application No.

KVPY - Online Application http://www.kvpy.org.in/kvpy-1314/preview.php

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