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HUMANITIES & SOCIAL SCIENCES ENTRANCE EXAMINATION - 2018

INDIAN INSTITUE OF TECHNOLOGY MADRAS


APPLICATION FORM

Application No: N611010508


1. Name of the Candidate as in the 10 th : VINAY YERUBANDI
Class Certificate
2. Name of the Parent / Guardian as in : VENKATA RAMANA MURTY YERUBANDI
10 th Class Certificate
3. Year of Passing Class 10 th : 2016 N
or its Equivalent 6
4. Year of Passing or Appearing : 2018 1
Class 12 th / Qualifying Exam 1
5. Gender : Male 6. Date of Birth : 12-06-2000 0
1
0
7. Category : General 8. Person with Disability(PwD) : No 5
0
9. Nationality : Indian 8

Complete Mailing Address

10. Address 4-4-101,OPP BHASYAM SCHOOL


KURASAALA VAARI STREET
AMALAPURAM
EAST GODAVARI

11. Pincode 533201

12. Mobile Number 8328142988

13. Email Address vinayyerubandi11@gmail.com


Choice of Examination City

1 st Choice of Exam City : 605 - Chennai

2 nd Choice of Exam City : 608 - Hyderabad

Payment Details

Payment Mode : Online Registration Fee : 2400.00

Reference No : LSBI5973189602

DECLARATION BY THE CANDIDATE


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 the Information Brochure of HSEE - 2018 and I shall abide
by the terms and conditions therein. In the event of my not satisfying the eligibilty criteria. I understand that I will be denied the opportunity to appear in HSEE and if already appeared or
admitted to the MA Program, my admission / degree acquired is liable for cancellation. I also understand that the decision of the HSEE Commitee regarding my admission to IIT Madras is
final and I shall abide by the decision. Further, if admitted, I promise to abide by the rules and norms of discipline of IIT Madras.

Signature of the Candidate

Certificates uploaded

Class X certificate : Uploaded Class XII certificate : Not Applicable

Caste Certificate : Not Applicable PwD Certificate : Not Applicable

OBC-NCL-Undertaking : Not Applicable

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