Samet Application Form 2010-11

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SPRINGDALE ACADEMY OF MARITIME EDUCATION AND TRAINING TRUST SAMET Application Form for Admission

Course Applied for

Affix your passport size colour photograph here

Month (Intake), Please Tick one January

April

July

October

Please note about the deadline of Application form Submission You application for must reach SAMET 2 months before the respective course intake and start of the beginning session.

PART A

Particulars of the Applicant Your Name Gender Date of Birth Nationality State Marital Status, Please Tick one

Single

Married

Divorced

Travel document/ Passport Number Country of Issue Place of Issue of Expiry date of the Travel document Applicant’s permanent Address as per the Passport

Applicant’s permanent Address if different from the above

Telephone number (with STD code if any) Mobile number (with STD code if any)

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Widowed

Others


PART A continued Applicant’s Parents info

Full Name

Relationship

Date of birth

Nationality

Occupation

PART B

Academic/ Professional Qualification of the Applicant Qualification 1 Name of School/ College/ University/ Institution Qualification obtained

Year of the Qualification obtained

Country/ State of the Institution Period of Study from

to

Qualification 2 Name of School/ College/ University/ Institution Qualification obtained

Year of the Qualification obtained

Country/ State of the Institution Period of Study from

to

Qualification 3 Name of School/ College/ University/ Institution Qualification obtained Country/ State of the Institution Period of Study from

to

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Year of the Qualification obtained


PART B continued

Academic/ Professional Qualification of the Applicant Qualification 4 Name of School/ College/ University/ Institution Qualification obtained

Year of the Qualification obtained

Country/ State of the Institution Period of Study from

to

Qualification 5 Name of School/ College/ University/ Institution Qualification obtained

Year of the Qualification obtained

Country/ State of the Institution Period of Study from

to

Qualification 6 Name of School/ College/ University/ Institution Qualification obtained

Year of the Qualification obtained

Country/ State of the Institution Period of Study from

to

PART C

Applicant’s Financial support Applicant’s Study Loan Applicant’s Father

Average monthly income INR for the past 6 months Current Savings

INR

Average monthly income INR for the past 6 months Current Savings

Applicant’s Relative

Applicant’s Mother

INR

Other financial support

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INR

Average monthly income for the past 6 months Current Savings Average monthly income for the past 6 months Current Savings


ANTECEDENT 1. Have you ever been refused entry into or deported from any country, including India?

YES

NO

2. Have you ever been convicted in a court of law in any country, including India?

YES

NO

3. Have you ever been prohibited from entering India?

YES

NO

4. Have you ever entered India using a different Passport or Name?

YES

NO

If your answer is “YES”, please furnish details on a separate sheet of paper

CONDITIONS FOR THE APPLICATION Applicant’s must read it before Agreement

1. A Non-Refundable Application fee of INR 40,000.00 payable to Springdale Academy of Maritime Education and Training Trust (SAMET) must be forwarded together with this application form. 2. Upon successful Student Pass Application SAMET will send the conditional offer letter and the “Standard Student Contract” to you. The Student must then ensure that the duly signed “Standard Student Contract” together with the Course Fee reach at SAMET least 1 WEEK before your arrive in SAMET Bhubaneswar. 3. Application MUST be supported by certified true copies of all relevant documents. SAMET reserves the right to disqualify the applicant for failure to do so. 4. Refund of Course Fees, if any, will be as stipulated in the “Standard Student Contract” signed between SAMET and the Student. 5. There shall be no refund of the Application Fee of INR 40,000 that accompanies this Application under any circumstances if the application is accepted. 6. Application Form duly completed and signed with all the supporting documents and the Bank Draft for

DECLARATION

Applicant’s must read it before Agreement I affirm that all the statements given in this application are true and accurate to the best of my knowledge. I have not deliberately omitted any relevant fact. Should I be admitted to SAMET on the basis of the above information which should later turn out to be false or inaccurate, I understand that I will render myself liable to appropriate action, including civil action, disciplinary action, dismissal from course, forfeiture of fees, fine and other disciplinary measures. I understand that SAMET has the sole discretion to reject any applications. I agree to abide by the decision of SAMET concerning this application and accept that SAMET reserves the right to withdraw any projected course intakes if there are insufficient applicants.

Name of the Applicant

Signature of the Applicant

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Date/ Place


POLICY ON CONFIDENTIALITY OF STUDENT DATA SAMET is committed to maintaining the confidentiality of the Student’s personal information and undertakes not to divulge any of the Student’s personal information to any third party without the prior written consent of the Student.

TWO MODES OF PAYMENT FOR APPLICATION & COURSE FEES We wish to inform students that there are two modes of Payment to SAMET: Either through a Bank Draft or Telegraphic Transfer (Wire Transfer). Typically, for smaller amounts (such as the Application Fee), sending funds by Bank Draft would incur lower Bank Charges. The Student may wish to enquire with their Bank before deciding on the Mode of Payment. Payment by Bank Draft If the Student wishes to send the relevant Fee(s) to SAMET through Bank Draft, the relevant details are as follows: Bank Draft must be made payable to “SPRINGDALE ACADEMY OF MARITIME EDUCATION AND TRAINING TRUST”. On the reverse side of the Bank Draft, the Student is requested to include his Full Name, Passport Number, and the Course he is applying for (indicate as appropriate: “Deck Cadet Programme Application”). Bank Draft must be sent to WMI via Air Mail together with the Application.

Please note The information you provide in this application is for internal use only, and will not be divulged to any third party without the students’s consent

FOR OFFICIAL USE ONLY

This section must only to be filled in by SAMET/ or its Representative Staff Date of Application submission Admission Acceptance Status, Please Tick one

Accepted

If refused, the reason(s) for refusal is/ are Assessed by Signature Date/ Place

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Refused

Keep in View (KIV)


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