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Application Form for Registration to Common Proficiency Test Course

July, 03rd 2014

Application Form for Registration to Common Proficiency Test Course

1.Name in full (As per SSC X certificates)
First Name:
Middle Name:
Last Name:
2.Sex:	Male Female
3.Date of Birth:
4.(a)Mother's Name:
4.(b)Father's Name:
5.(a)Address For Communication:
Address Line 1:
Address Line 2:
Address Line 3:
Address Line 4:
City:	State Code:
Pin:	Phone No. with STD Code:
Country:
Email id:	Mobile No.:
5.(b)Permanent Address Same As Communication Address given in 5(a) above: Yes No
Address Line 1:
Address Line 2:
Address Line 3:
Address Line 4:
City:	State Code:
Pin:	Country:

Please fill the circle as applicable: (Enclose proof thereof)
6. Category	Gen SC/ST Backward Class OBC Disabled
7. Nationality:	Indian Foreign National
8. Medium of study:	English Hindi
9.Details of Educational Qualifications: Starting from 10th standard

10. Annual income of Parents: INR $
11. In case an existing student of Professional Education (Course-I/II) wants to switch over to CPT, please provide your Unique Registration No.(i.e.,WRO/SRO/NRO....)	eg:- _RO_ _ _ _ _ _ _

12.
	(a) India National residing in India Rs.6100/-
	(b) Indian National residing in SAARC Countries Rs.6100/-
	(c) Indian National residing in a place other than (a) & (b) US$590 (US$580 + US$10)
	(d) Foreign National belonging to SAARC Countries Rs.6100/-
	(e) For other than stated in (d) above US$590 (US$580 + US$10)

13.	Details of course Fee for new registrants
	Registration Fee Rs.6000/- for students stated in 12(a),(b) & (d); and US$ 580 for students stated in 12(c) & (e) Cost of CPT Prospectus Rs. 100 for India/SAARC Students and for others US$ 10
	Subscription for Student's Journal Rs.200/- (for India/ SAARC Students) and for others US$ 20 (for one year)(Optional but strongly recommended)
	Subscription for Member's Journal Rs.400/- (for India/ SAARC Students) and for others US$ 40 (for one year)(Optional)

Date:	03-07-2014
Place:

Total payable amount:

INR 6100/-