13/08/11 11:01 AMKVPY - Online Application

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APPLICATION FORM - 2011

Your application for "Stream SX" has now been incorporated into our system and you have been

assigned the Application number 1160209.

Stream SX

Application No. 1160209 1 Name of Candidate (as in 10th Marks Card) : Saurabh Uday Shringarpure2 Date of Birth (dd/mm/yyyy) : 07/07/1994

3 Category : General4 Nationality : Indian5 Gender : Male Exam Board Science Maths Physics Chemistry Biology Others Aggregate6 X Std

(% marks)CBSE 100 100 N/A N/A N/A N/A N/A

7 XII Std (% marks)

CBSE N/A NA NA NA NA NA NA

8 In the academic year 2011-2012 I have joined XII Standard in Science Subjects 9 Centre for writing Aptitude Test (for SA, SB and SX only) : Bhopal10 Language in which would like to take your Aptitude Test : English 11 Name of College/Institution : Cambridge International School12 Address of College/Institution : Khandwa Road

Indore-452001Madhya Pradesh

298, First FloorIndrapuri Colony

IndoreMadhya Pradesh45200107314261046wystra@gmail.com

Candidate Signature:

CERTIFIED BY THE COLLEGE/INSTITUTION

Mr. Saurabh Uday Shringarpure is a bonafide student of Cambridge International School and his

date of joining XII Standard in Science Subjects is on:

and all the information furnished by the applicant is correct.

Date:

Place:

Signature of the Head of the Institution

Name:

Institution Seal:

13/08/11 11:01 AMKVPY - Online Application

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However, your application is not complete until you do the following:

1. Take a print out of this Application Form and make sure that it is complete with a applicationnumber and your signature. Please also obtain your School / College Principal’s signature and sealin the appropriate place. Do not make any changes / alterations to this page.

2. Application Processing Fee: * ** Processing fee for application is Rs. 200/- (Rs. 100/- forSC/ST candidate) by means of remitting Rs. 200/- (Rs. 100/- for SC/ST candidate) “toany core banking branches of STATE BANK OF INDIA, payable at all branches in India. Paidinto the credit of "Kishore Vaigyanik Protsahan Yojana(KVPY) A/c. No. 10270577392" andsend the “Pay-In-Slip” (Applicants are instructed to download the “Pay-In-Slip” from KVPYweb site - http://www.kvpy.org.in/) along with the Application, clearly indicating the stream (SA,SX, SB, SP). Ensure that you also write the Application Number on the reverse of the Pay-In-Slipas well as other documents that you send along with this application.

* Girl students are exempted from payment of processing fee. ** Physically and visually challenged students are also exempted from payment ofprocessing fee.

3. For Stream SX – The student aspiring to join undergraduate program in Basic Sciences for thesession 2012 – 2013.

4. If you have obtained a letter grade in your qualification exam please convert into an appropriate %and fill-up in the application form.

5. Stream SP (Medicine) – The application must be accompanied by two recommendation letters inthe prescribed forms one form from Teacher / Instructor in your College/University and the otherfrom the Advisor/Supervisor of your KVPY project (Bio-Medical Project). Each recommendationletters must be placed in different envelopes, sealed and with signature of the person giving therecommendation across the sealed envelopes. These sealed envelopes must accompany with yourapplication.

6. Enclose the following :Caste certificate in the case of SC/ST candidateMedical certificate from the prescribed authority in case of physically and visuallychallenged candidates.Project report in the case of SP – Basic Sciences / MedicineOriginal Pay-In-Slip of the Processing fee of Rs. 200/- (Rs. 100/- for SC/ST).Attested copies of your marks statement of the qualifying examination(self attestation isacceptable ) for Stream SP only

7. Send all the above documents so as to reach on or before 12/09/2011 toThe Convener, KVPYIndian Institute of ScienceBangalore – 560 012.

8. Last date for closing of online application is 9th September 2011 at twelve O’ clock midnight9. You may check to see that your application is complete and all documents received at the KVPY

office by going to http://www.kvpy.org.in. Please allow at least 20 days after sending yourdocuments for postal delays for status information.

10. Issue of hall ticket – through KVPY website (for online applicants only for SA, SX, SB): WebsiteURL: http://www.kvpy.org.in/Login ID – Application numberPassword – Date of Birth

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