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Decla

The document is an Acknowledgement & Declaration Form for Siddharth Priyadarshan, who is applying for admission to the CLASS VI PHASE-II course at the Bhubaneswar center for the 2022-23 session. It includes personal details, a declaration of responsibility for conduct and safety, and consent for the use of personal information for publicity. The applicant affirms the accuracy of the information provided and agrees to the institute's rules and jurisdiction.

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priyadarshansiddharth2010
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4 views1 page

Decla

The document is an Acknowledgement & Declaration Form for Siddharth Priyadarshan, who is applying for admission to the CLASS VI PHASE-II course at the Bhubaneswar center for the 2022-23 session. It includes personal details, a declaration of responsibility for conduct and safety, and consent for the use of personal information for publicity. The applicant affirms the accuracy of the information provided and agrees to the institute's rules and jurisdiction.

Uploaded by

priyadarshansiddharth2010
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Corporate Office:

“SANKALP”, CP-6, Indra Vihar, Kota, (Rajasthan) - 324005


Ph.: +91-744-275-7575
Website: [Link] | E-mail: info@[Link]

Acknowledgement & Declaration Form (Session 2022-23 )


Application form no: 22617813 Photograph

Name of Applicant: Siddharth Priyadarshan


Father's Name: Sanjay Kumar Sethi
Mother's Name: Banalata Sethi
Gender: Male Medium: English
Stream: Pre-Nurture
Center: BHUBANESWAR, RPC, MAITREE VIHAR
Course Name: CLASS VI PHASE-II / 4002
Plot No : 131 Punjabi Colony Satyanagar
Address: City: Bhubaneswar ,
District: Khorda , State: Odisha , Pin: 751007
Contact Details: Phone No.: - Mobile No: 9776672123
Email: sanjaytulu1979@[Link]

Declaration
I hereby declare
that I am seeking admission in my own interest and accord.
that I shall be fully responsible for any accident / mis-happening occurring with me/by me inside / outside the institute's
premises and institute will not responsible in any manner.
that I shall be responsible for my rustication on grounds of misconduct, misuse of mobile phones, misuse of internet or any
illegal and indecent activity.
that in case of my selection in Medical / Engineering Entrance Exams / NTSE & Olympiads, the institute reserves the right to
use my name, photo and other information for publicity purpose.
that I solemnly affirm that the institute has rights to send me emails (e-newsletters), sms alerts, WhatsApp Messages (Text,
Images, Video, Documents) and post on the mentioned communication details.
that all the information furnished by me in the ONLINE Application Form or in any other 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 of fee.
that I have read all the instructions of the Information Bulletin / available Online and I do agree to follow the instructions as
applicable.
that I agree to abide by the Refund Rules of the Institute.
I agree that all dispute are subject to Kota (Rajasthan) jurisdiction only.

Signature of Candidate Date: Signature of Father / Mother

Print Date: 22/Apr/2022 21:36:15

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