APPLICATION NUMBER 3136608 PAYMENT MODE DD

COURSE GROUP 2 AMOUNT 2000

COURESES/APPLIED [BTech] DD NUMBER 559601
TEST CENTER Bangalore,Belgaum DD DATE 02/4/2018
DATE OF BIRTH 03/4/2000 CATEGORY GENERAL
SEX Male NATIONALITY India
NAME OF THE APPLICANT OMKAR SUNIL GURAV
NAME OF THE PARENT/ SUNIL GURAV
GUARDIAN
ADDRESS LINE 1 72/1
ADDRESS LINE 2 hindu nagar
ADDRESS LINE 3 tilakwadi belgaum
PIN 590006 STD CODE/TELEPHONE NA
NUMBERS
CITY Belgaum E-MAIL ADDRESS omkargurav974@gmail.
com
STATE Karnataka MOBILE NUMBER +917204987956
DATE OF COMPLETION OF NA
INTERNSHIP
EXAM REG NUMBER NA EXAM ROLL NUMBER NA
EXAM NAME NA EXAM SCORE NA
EXAM RANK NA
FOR MD/MS FOR MTECH
APPLICANTS APPLICANTS
ARE YOU A DIPLOMA NA ARE YOU A GATE SCORER? NO
HOLDER?

DECLARATIONS:
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I
have read and understood all provisions of admissions and agree to abide by them. I also affirm that I fulfil the eligibility
requirements for the course/s applied. In the event of submission of fraudulent, incorrect or untrue information or
suppression or distortion of any fact, like educational qualification, marks, nationality etc. I understand that my admission/
degree is liable for cancellation. I further understand that my admission is purely provisional subject to the verification of the
eligibility conditions.
NOTE:
1.Please keep a copy of the filled in application for future reference.
2.Application number must be quoted in all future correspondence.
3.The candidates who are appearing for GATE exam should submit the valid score card on or before the last
date of receipt of application (For MTech / MSc Tech applicants only)
4.Please send this completed application form with DD/Challan(if payment is not via Credit Card) to: Director -
Admissions, Manipal Academy of Higher Education, Manipal - 576104