30/04/2018 ICAI

COMPOSITE APPLICATION FORM FOR ENROLMENT FOR REGISTRATION TO FINAL COURSE

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REF. NO.: FNALC000030215 
Registration Number: NRO0438193 

1. Name in full SANJANA  

2. Gender FEMALE 
3. Date of Birth 18-JUN-1999 
4(a). Father's Name CHARANJEET 
4(b). Mother's Name MANJU BALA 
5. Correspondance Address HOUSE NUMBER 28 
PUNJABI MOHALLA 
VPO AGROHA 
HISAR HARYANA 
  City HISAR, HARYANA, INDIA 
  Pincode 125047        Phone:  
  Email address SANJANATANEJA99@GMAIL.COM 
  Mobile number 9255943525 
6. Permanent Address HOUSE NUMBER 28 
PUNJABI MOHALLA 
VPO AGROHA 
HISAR HARYANA 
  City HISAR, HARYANA, INDIA 
  Pincode 125047        Phone:  
7. Category GENERAL 
8. Nationality INDIAN 
9. Foundation Course/PE-I/CPT Registration Number: NRO0438193 
10. Intermediate/PE-II/PCC/IPCC/Intermediate(IPC) Course Registration Number: NRO0438193 
11. Particulars of Passing the CPT/Intermediate/Professional Education(Examination-II)/Professional Competence Examination/Intermediate Professional Competence
Examination/Intermediatre(IPC)Examination
Course Type Roll No. Passing Year
 CPT   905873  JUN-2016
 INTERMEDIATE  BOTH GROUPS    JAN-1998
 INTERMEDIATE  GROUP I 376010  AUG-2017
 INTERMEDIATE  GROUP II 180196  JAN-2018
12. Medium of Study ENGLISH 
13. Name of Elective Paper FINANCIAL SERVICES AND CAPITAL MARKETS 
14. Details of Compulsory Computer Training/Information Technology Training/ICITSS(IT)
a. Name of the Regional/Branch Office where
HISAR BRANCH
student has registered for IT Training
20-12-2017
  b. Date of appearence in Final Online Test HISAR/IT/0000103
c. ITT Certificate No. 21-12-2017 
d. ITT Certificate Date
15. Details of Orientation Programme/Orientation Course/ICITSS(OC) Certificate details(if student is from IPCC/IIPCC/Intermediate Course)
a. Certificate No. HISAR/OC/0000184
  b. Certificate Date 18-01-2018
c. Issued by Branch/Regional Office HISAR BRANCH 
16. Details of Advanced ICITSS(IT)
a. Name of Branch/Regional Office where student
has registered for IT training
  b. Date of appearance in Advance ICITSS(OMR Test)
c. Advance ICITSS(IT) Certificate No.  
d. Advance ICITSS(IT) Certificate Date
17. Details of Advanced ICITSS(MCS) Certificate details
a. Certificate No.
  b. Certificate Date
c. Issued by Branch/Regional Office  
18. Final Registration Fee*(for Indian) Rs. 22,000
Final Registration Fee*(for foreign students) US$1100*
TOTAL AMOUNT: 22000 
DECLARATION
I hereby declare that all the information above is true to the best of my knowledge.
 

Date: 30/04/18 
(within the frame only)
Signature of the Applicant
ACKNOWLEDGEMENT
REFERENCE NUMBER FNALC000030215
TXN.ID 7742027964
DATE 2018-04-30 10:31:03.0
BANK Punjab National Bank
AMOUNT 22000.00/-
DOCUMENTS ATTACHED

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LEAVING CERTIFICATE

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ICITSS CERTIFICATE

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