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The Institute of Chartered Accountants of India - COMMON PROFICIENCY TEST - June, 2013

Name of Candidate : SHUBHAM NAVALKISHOR RATHI Gender : MALE CPT Reg. Date : 10/07/2012 Date Of Birth : 05/11/1995 Control No: 512859 E Mail : shubham2167@gmail.com Registration No : WRO0470448 Center Selection Mobile No : 7276118374 Landline No : PIN :2167 Region : WESTERN REGION City :AKOLA Question Paper Booklet Language : ENGLISH Address C/O NIRAJ RATHI
KHAN FORTE,BEHIDN RLT COLLEGE COLLECTOR COLONY AKOLA - 444001 MAHARASHTRA , INDIA

Father's Name : NAVALKISHOR RATHI Details of Latest Previous appearances in CPT : MM : YYYY : Roll No.:

Academic Details of Qualifying examination (i.e., 12th Class examination) : ALREADY APPEARED Year : 2013 % of Marks secured in 12th class Examination : Roll No
:

V071680

Board of qualifying examination (i.e., 12th Class examination or equivalent) : STATE BOARD Payment Details Transaction Date: 07/04/2013 Amount: 500 INR Bank Transaction No: EFC_WRO0470448_1318622943

Declaration by the student I SHUBHAM NAVALKISHOR RATHI Son/Daughter of NAVALKISHOR RATHI request for permission to present myself at the Common Proficiency Test conducted by the Institute of Chartered Accountants of India. I hereby declare that the particulars stated in this application form are true to the best of my knowledge and belief. I have read the Guidance Notes for candidates and satisfied myself that I am eligible to appear in ensuing CPT to be held in June, 2013 and I shall abide by the terms and conditions therein. I understand that my admission to CPT and result thereof shall be provisional and subject to verification of my fulfilling the eligibility requirements in terms of Regulation 25D (as explained below) of the CA Regulations, 1988 and decision of the Council of ICAI. In the event of suppression or distortion of any fact made in this application form, I understand that I shall be denied the opportunity to appear in CPT and if already admitted / appeared, my admission / result acquired shall be liable for outright cancellation. I also understand that the decision of the Institute in this regard shall be final and binding upon me and I shall abide by the same.

Paste firmly with glue or adhessive like fevicol (Do not staple) recent color photograph of size 3.5 X 4.5 cms Signature of the Parent/Gaurdian (Sign within the box with blue/black pen) Dated : 07/04/2013 ATTESTED PHOTO Signature of the Candidate (Sign within the box with blue/black pen)

Paste firmly with glue or adhessive like fevicol (Do not staple) recent color photograph of size 3.5 X 4.5 cms

NON ATTESTED PHOTO

I do hereby certify that the photograph affixed above is that of MR./MS SHUBHAM NAVALKISHOR RATHI Son/Daughter of NAVALKISHOR RATHI, who has signed in my presence. I have verified and satisfied that the candidate named above is registered for CPT course with the Board of Studies of the Institute on or before 2nd April, 2013 and has already passed/already appeared / will be appearing in 12th class examination in March/April, 2013 and is eligible as per Regulation 25D(as explained below). The particulars as furnished have been verified by me and found correct with reference to the documents produced before me by the candidate. Date: Place: Signature of Member of ICAI/Head of Educational Institution /Gazzetted Officer Name and membership No.of the Member of ICAI /Head of the Educational Institution /Gazzetted Officer with Seal Tel No._________________________

Important: Please do not fold this document while posting Explanation of Regulation 25D: 1. The candidate should be registered for CPT course with BOS of ICAI on or before 2nd April, 2013. 2. The candidate who has passed 12th class or equivalent examination or appeared in 12th class or equivalent examination or will be appearing in 12th class or equivalent examination in March/April, 2013 will be eligible to appear in CPT exam to be held in June, 2013.Refer Guidance Notes for latest Council decision.