IIT-JEE 2014

For Office Use only

12, Masilamani Street, T. Nagar, Chennai 600 017. Student No:

4 Affix Passport Size Photo here 4.5 4.5 cms Enclose two signed photographs with this Form (Enrolment forms will not be accepted without three photographs)

ENROLMENT FORM ONE-YEAR POSTAL SUPPORT PROGRAMME FOR

IIT-JEE 2014
The Principal, BRILLIANT TUTORIALS PVT. LTD. Sir,
PLEASE ENSURE THAT THIS IS THE COURSE YOU WISH TO APPLY AND ENROL FOR. COMPLETE AND SIGN BOTH SIDES OF THIS FORM.

I am/was studying in .......................................................................................(Name and Location of School) Board : CBSE ICSE State Other Please specify

I will be entering Std XII in (Month/year) I am studying in Std XII.

Have you previously enrolled in any BT Course? Yes Enrolment No.

I have passed Std XII. but will appear for IIT-JEE in 2014. Please enrol me as a student of: One year postal course with Y.G.File One year Y.G.File course I will take the Tests On-line. My e-mail address: I herewith remit the full course fee of 1 Yr. Postal Course Y.G. File

REFERENCE NUMBER:

No

T ......

If Yes, Course ......

Rs. 18,069/Rs. 11,191/-

by

MO/DD drawn in favour of Brilliant Tutorials Pvt. Ltd., payable at Chennai. MO Receipt / DD No. Bank Date Net Banking/Credit Card/Online Bank Transfer ___ (Bank routing instructions given below) Transaction Confirmation No. Date Cash/ Credit Card at your Centre in Credit Card Authorization Code Last 4 Digits of Card No. *I would like to receive all updates and/or promotional materials as text messages on my cell phone number given below Yes No (Please 3 the appropriate boxes) I have read and shall abide by the rules and regulations for this Course given in the Online / Hardcopy Prospectus. Fees once paid will not be refunded or adjusted under any circumstances. BANK ROUTING DETAILS All matters are subject to the exclusive jurisdiction of courts in Chennai only. Yours faithfully, Signature of Applicant Date: Signature of Parent/Guardian Relationship to applicant
Visa Master Card

Pay to: BRILLIANT TUTORIALS PVT LTD. Account No. 014010200034654 Bank, Branch: AXIS BANK LTD, T.NAGAR BRANCH, CHENNAI 600 017. IFSC Code For NEFT: UTIB0000014 Note: Payment by NEFT only. Bank charges to be paid by student.

(PLEASE PRINT IN BLOCK LETTERS)

APPLICANTS NAME (as in school records) ..: Date of Birth : Date Month .. Year Permanent Home Address: Telephone Number: STD Code: E-Mail:*

Sex:

Male

Female

Cell Phone: * PIN CODE:

Fax: Name and Full Postal Address to which all Correspondence and study material should be despatched: Telephone Number: Fax:

STD Code: E-Mail:*

Cell Phone: * PIN CODE:

Our course material is in the English Medium only Fees once paid will not be refunded or adjusted under any circumstances. No instalment facility. Application will not be accepted without the photograph. PIN CODE, AN ABSOLUTE MUST. Your application for admission will not be accepted unless your address is complete with Pin Code. *Denotes mandatory fields. Brilliant Tutorials reserves the right to use the photographs and/ or testimonials from the student in promotional / publicity material. REMEMBER TO SEND TWO ADDITIONAL SIGNED PHOTOGRAPHS (preferably colour) WITH THIS FORM Please keep a copy of this application for your records