12/24/13 KLEU-PGAIET-2014 APPLICATION FORM

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KLE ACADEMY OF HIGHER EDUCATION
AND RESEARCH DEEMED UNIVERSITY
Accredi ted by NAAC wi th 'A' Grade Pl aced i n Category 'A' By
MHRD(GoI)
(Establ i shed under secti on 3 of the UGC Act,1956 vi de Government of
Indi a Noti fi cati on No. F.9-19/2000-U.3 9AO)
KLEU - PGAIET - 2014 APPLICATION FORM
Application No.
M14636130
Course : MEDICAL
Name of the Candidate : ADITYA
Father Name : PRADEEP KUMAR
Date of Birth : 06/12/1983
Photo and Signature
Gender : MALE
Address : SAI NIWAS, HOUSE NO 70
BHAGIRATHIPURAM, JAKHAN
NEAR RAJPUR ROAD
City : DEHRADOON
Pincode
:
248001
State : UTTARAKHAND
Telephone :
0135-
8171176355
Mobile : 8171176355
Month-Year Of Passing: 8 / 2007 Intership Completion : 9 / 2008 Category : GENERAL
Email : adi.gatsby@hotmail.com
Choice Of Centre : 14-NEWDELHI
Declaration - I :
1. I hereby declare that the above inf ormation is true and complete to the best of my knowledge. I am aware that if any inf ormation
herein is f ound to be incorrect or incomplete, my application f orm will be rejected / admission will be cancelled.
2. If admitted to any of the constituent units of KLE Academy of Higher Education and Research Deemed University, Belgaum. I
shall abide by its Rules and Regulations.
3. I have read and understood all the provisions contained in the brochure and hereby agree to abide by these provisions.
4. I am aware that, any legal matters arising out of the total admission process of any Course through KLEU PGAIET-2014 will be
in the courts of Belgaum.
Date : ______________ Place : _____________
Left Thumb Impression of the candidate Full Signature of the Candidate
Declaration - II :
I, the parent / guardian of the applicant hereby declare that I am aware of the f inancial obligation of admitting my child / ward to the
college of the constituent units of KLE Academy of Higher Education and Research Deemed University, Belgaum. I agree to pay the
tution other f ees payble to the institution as f ixed f rom time to time as per the rules. I also af f irm and endorse the declaration made
above by my child / ward.
Date : ______________
Place : _____________
Signature of the Parent / Guardian
Acknowledgement
12/24/13 KLEU-PGAIET-2014 APPLICATION FORM
kleuniversity.edu.in/KLE/WebPages/Report.php?id=NjEzMA== 2/2
Order ID : 6130 Candidate Name : ADITYA Amount : 3200.00 Rs.
This Acknowledgement is valid after realization of payment. Registrar KLE University