NEST-2009 Form
Application Number : D (Barcoded)
1 Name First name ____________________________________




Affix your recent color passport photo,
not larger than this box
Middle name ____________________________________
Last name ____________________________________
2 Applying for NISER    UM-DAE CBS    Both
3 Subject pref.
(UM-DAE CBS only)		 Physics    Mathematics    Biology
4 Category General    SC    ST    OBC
5 Physically Disabled? YES    NO
6 Gender Male    Female
7 Date of Birth Day ________/  Month ________/  Year ____________/
8 Place of Birth ____________________________________
9 Address for Correspondence ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PIN Code__/__/__/__/__/__/
10 Contacts Telephone ____________________________________/
Fax (if any) ____________________________________/
e-mail ID ____________________________________/
11 Test Centre Choice First ____________________________________/
Second ____________________________________/
12 Academic Record Class
Year Board/Council Percentage
________/ ____________________________________/ ________
________/ ____________________________________/ ________
10th/Equiv.
12th/Equiv.
13 Name of Guardian
(as in Xth certificate)		 ____________________________________
14 The guardian was your... Father    Mother    Uncle    Aunt    Other, specify__________
15 Payment Details Amount of DD __/__/__/ Rupees
DD Number________________   Made on date  ________________
Bank name_____________________________________________
Declaration by the candidate
I hereby declare that all the particulars stated in the application are true to the best of my knowledge and belief. I have read the information brochure and I shall abide by the terms and conditions therein. I understand that in the event of suppression or distortion of any fact, my admission is liable to be cancelled. Further, if admitted, I promise to abide by the rules and regulations of the respective institute.
Yes, I have read the brochure and I agree to sign the declaration.
Place :
Signature of the candidate
Date :
Name of the Guardian
Countersigned by Parent/Guardian
 
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