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COUNSELLING CUM REGISTRATION FORM

(Please fill in all Particulars CLEARLY)

PERSONAL DETAILS

First Name

Middle Name

Last Name

Date of Birth

Place of Birth

Nationality

Identification Mark

Tattoo/Piercing/Body Mark / Birth Mark (if any)

Gender

Male

Female

Marital Status

PERMANENT ADDRESS

City/Town

Pincode

State

Mobile No.

Alternate No.

Email-ID

FAMILY DETAILS

Father Name

Father Occupation

Mother Name

Mother Occupation

Siblings(if any)

ACADEMIC RECORD

Year of Passing	Board	School	Percentage (without % symbol)
Class 10^th Class

Subject	Mark	Percentage (without % symbol)
ENGLISH

Year of Passing	Board	School	Percentage (without % symbol)
Class 12^th (SCIENCE)

Subject	Mark	Percentage (without % symbol)
PHYSICS
CHEMISTRY
MATHEMATICS

Year of Passing	Board	School	Percentage ( without % symbol )
Class 12^th (ARTS/COMMERCE) Note - 12th pass out arts or commerce students only need to submit class 10th details.

Stream	Year Passed	University/ College	Percentage (without % symbol)
Diploma/ ITI (Electrical Engineering)
ELETRICAL

Stream	Year Passed	University/ College	Percentage (without % symbol)
Graduation/Degree
ELETRICAL

Tell Us about your self (In Brief):

Candidate Signature

Note- Please attach your 10th, 12th, Degree or Diploma certificate and marksheets on this mail to process your application, Email - ubseaandshoreservices@gmail.com.

Declaration

I, hereby, confirm that the information given by me is true and factual to the best of my knowledge. On Admission, I understand to attend all classes regularly and punctually and to comply with all the regulations of the institute

Note-If I found medically unfit, the registration fee is refundable

COUNSELLING CUM REGISTRATION FORM

(Please fill in all Particulars CLEARLY)

PERSONAL DETAILS

PERMANENT ADDRESS

FAMILY DETAILS

ACADEMIC RECORD

Class 10th Class

Class 12th

Class 12th

Diploma/ ITI (Electrical Engineering)

Graduation/Degree

Declaration

Class 10^th Class

Class 12^th

Class 12^th