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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
Examination Board/Authority Year Result
Marks Obtained Max Marks Awaited
10th  
12th Yes
Degree Yes
Diploma Yes
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: 21-09-2014
Place:
Total payable amount:
Select a payment gateway:
ICICI Bank
Credit/Debit Card
 
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