(STUDENT REGISTRATION COPY)

SHIV TECH PRASHIKSHAN SANSTHAN

Address : 201 Ganesh Madiya, Bada Bazar, Jhansi, Uttar Pradesh - 284002
Mail ID : shivtechjhansi@gmail.com | Contact No : +91 8318100448

STUDENT REGISTRATION FORM

Registration No : SHIV20267776 Date & Time : 29-07-2026 02:34 PM Roll No : 20267424
150
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SIGNATURE

Declaration

I hereby declare that all information provided by me is true and correct to the best of my knowledge.

*** SYSTEM GENERATED RECEIPT ***

SHIV TECH PRASHIKSHAN SANSTHAN

201 Ganesh Madiya, Bada Bazar, Jhansi, Uttar Pradesh - 284002

PAYMENT CUM REGISTRATION RECEIPT (OFFICE COPY)

Registration No: - Date & Time: 29-07-2026 02:34 PM Roll No: -
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SIGNATURE
STUDENT PROFILE & ADMISSION DETAILS
Student Name: -
Father's Name: -
Mother's Name: -
Mobile Number: -
Date of Birth: -
Gender / Category: - / -
Email ID: -
Full Address: -
Qualification / Course: - / -
Batch Timing Selection: -
ID Card Number: -
Blood Group / Emergency No: - / -
FEE TRANSACTION DETAILS
Paid Amount: ₹ 150.00 (Rupees One Hundred and Fifty Only)
Transaction / UTR No: -
Payment Status: SUCCESS (SUBJECT TO VERIFICATION)
Student Declaration (Office Record):

"I hereby declare that all information provided by me is true and correct to the best of my knowledge. I completely agree to the institute admission rules and regulations."

✓ Electronically Verified & Agreed by Student
Student Signature: _________________ Authorized Signatory: _________________