Praxair Proactive – Education Support Program

Application Form

  1. Name of Candidate: (IN BLOCK LETTERS):………………………………………………………………………………………….
  2. Address: …………………………………………………………………………………………………………………………………………………………………………………………………………………….
  1. Date of Birth (dd/mm/yy):…………………………………………………………………………………………..
  2. Male/Female/Other:…………………………………………………………………………………………
  3. Name of Father:…………………………………………………………………………………………
  4. Annual income:………………………………………………………………………………………
  5. Name of Mother:………………………………………………………………………………………
  6. Mother’s occupation:…………………………………………………………………………………
  7. No. of siblings (brothers /sisters) and their age:……………………………………………………………………………………………

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  1. Number of total dependents in the Family:…………………………………………………………………….
  2. Name of current course registered/applied for:……………………………………………………………..
  3. Name of Institution:…………………………………………………………………………………………………………
  4. Address:………………………………………………………………………………………………………………………………………………………………………………………………………….
  5. What is the fee for current course …………………………………………………………………………………………………….
  6. Extra Curricular Activities:……………………………………………………………………………………..

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  1. Contact Number: – minimum 2 contact numbers needed

Contact number 1……………………………

Contact number 2. …………………………

  1. Fathers’ Bank account details ( Name of the Bank, Account Number, Branch, IFSC code)

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  1. Documents needed
  • Passport size photos – 3
  • One ID /address proof
  • Prof of fees paid to school, colleges ( challan, reciept )

     19. Details of Praxair Contact person

Name ……………………………………………………

Contact Number ………………………………………..

Email ID ………………………………………………….