Preffered Study Center

Stream

Course

Name of Student

Name of Father

Name of Mother

Name of Domicile

Date of Birth

Gender:

Category

Permanent Address

 

City/Town/Village

 

District

 

PINCODE

 

Country

 

Phone/Mobile (Self)

 

Phone/Mobile (Parent)

E-mail (Self)

 

E-mail (Parent)

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Past Academic Performance

ClassYear Of Passing OutName of SchoolCityStateBoard%MarksSC+MTHS/PCM/PCB
VII
VIII
IX
X
XI
XII

Emergency Mobile/Telephone Number/Email (Other than Parents):

How did you come to know about Potential Coaching Institute:

DECLARATION BY STUDENT

I hereby declare that the following information given in this application form and other documents is complete and accurate to the best of my/my wards knowledge. I understand and agree to the facts that misrepresentation or omission of the fact will justify the denial/cancellation of my/my wards admission or expulsion from the institute. I have read and do hereby adhere to the terms and conditions provided to me/my ward from the institute during the time of my/my wards admission. Further i promise to abide by the rules and regulations and the norms of discipline of the institute as long as i/my ward remain/remains a registered student of Potential Coaching Institute.

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I Accept