Note : 1. Data Sheets are to be submitted in three copies along with required enclosures (Transcript/ marksheet of class XII and English translated citizenship certificate).

2. Before filling this Form, read the instructions carefully. All entries should be made in Capital Letters.

(i) Choice of Examination Centre (Kathmandu or Birgunj)
Please write one center only in the box / è

(ii) Out of the six courses given below, choose only two courses and indicate in the box. More than two courses are not allowed. è

/ COURSE – I
1.  MBBS [SFS]
2.  BE [Scholarship]
3.  B.Pharma [Scholarship] / 4.  B.V.Sc [Scholarship]
5.  B.Sc Dairy Tech. (Scholarship)
6.  B.Sc (Ag) (Scholarship)
COURSE – II
(iii) If opting for BE, indicate preferred branch of Engineering è / Choice – I / Choice – II / Choice - III
(iv) Have you appeared in SAT Exam 2013 year (Please tick) /
Yes No

1.  Candidate's Name (in capital letters) (please keep one box blank between name, middle name & surname)

2. Father's Name (in capital letters) [Father’s Occupation: ______]

3. Mother’s Name (in capital letters) [Mother’s Occupation: ______]

4. Date of Birth
a. In Christian Era b. In Birkram Samwat c. Age as on 1st July, 13

DAY MONTH YEAR DAY MONTH YEAR DAY MONTH YEAR

5. Correspondence Address (in capital letters in English) Signature of Candidate â

6.

7. / Permanent Address / 8. Details of Nepalese Citizenship
(Please attach photocopy)
a. Citizenship No : ______
b. Issuing Date : ______
c. Place of Issue : ______
______
______
District : ______
Telephone with code:______
Email Address: ______

9. (i) Educational Qualification with name of Institute and year of passing

(Please attach attested photocopies of mark sheets and fill the column as applicable otherwise keep blank)

Name of Examination / Year of
Passing / Institute / Total Marks / Marks Obtained / Aggregate
%age / % age in Eng
Class – XI
Class – XII
(If appearing, keep the columns blank, attach recommendation letter of concern college, mark sheet of class XI and write “Appearing”)

(ii) Percentage of Marks (wherever applicable)

Choose only two courses and indicate in the box. More than two course are not allowed / For BE /B. Sc Dairy Tech
Marks in:
Physics Chemistry Math % in PCM / For MBBS/ B.Pharmacy/ BVSc/ B.Sc(Ag)
Marks in:
Physics Chemistry Biology % in PCB
Class – XI
Class – XII
(If appearing, keep the columns blank, attach recommendation letter of concern college, mark sheet of class XI and write “Appearing”)

10. Details of any other scholarships received previously from Embassy of India or any other Organization:

______

______

I hereby certify and declare that:

I certify that information / details furnished in the above data-sheet is correct to the best of my knowledge and belief. I am also aware that my application will be rejected if any fact stated above is found to be incorrect. I have also understood the terms and conditions mentioned in the notice and I would abide by the same.

I do, hereby declare that I fully understand that mere nomination by the Embassy of India in the COMPEX- examinations will not ensure me any seat in my subject for studying in India, and that, in case the Indian Universities/ educational institutions subsequently deny me admission, I shall have no right to avail scholarship/ seat under COMPEX Nepal Scheme. I will not request for change of college/ institution or transfer of scholarship on receipt of admission offer letter. If I withdraw or reject the scholarship offered by the Embassy due to non- placement in a college/ institution of my choice, I will be debarred from future scholarship of the Embassy.

DATE: ______

______

PLACE: ______Signature of Candidate

For appearing candidates

UNDERTAKING

(APPEARING CANDIDATE)

I do, hereby declare that I fully understand that if on declaration of my Class XII results and receipt of mark- sheet of the same, it is found that I do not satisfy the eligibility criteria as required for the COMPEX- Nepal Scheme, I shall lose any further claim on my nomination under COMPEX Nepal 2013-14.

SIGNATURE

NAME

DATE