ENROLMENT FORM

Enrolment No. :
(For official use only)

Correspondence Programs

FIITJEE

(To be filled by the student) Name of Program Enrolling for :

(for list of Programs see page no. 4)

Please Affix Your Recent Passport Size Colour Photograph

Preference of Test Centre for AITS for JEE (Main & Advanced) :
(for list of Test Centres see page no. 3)

Name of the Student Fathers/Guardians Name Mothers Name Date of Birth Correspondence Address

: : : : :
D D M M Y Y Y Y

Nationality :

Pin : Ph. (Res.) with STD Code : Permanent Address : Mobile No. ** :

Pin : Ph. (Res.) with STD Code : School affiliated to Class : : CBSE IX X Board X Board- Science General ICSE XI . % Maths Mobile No. : Other (Please Specify) _______________________ XII XII (Pass) XII Board XII Board- P . C % M

Marks in Sci.+Math/PCM (%) Obtained : Marks (if in Grades) Category of Student E-mail ID of the Student
(in Block Letters)

: : :

Other (Please specify) ____________________________

** Please mention if you want to receive information through SMS on this mobile:

Yes

No

FIITJEE Limited, 1st Floor, Building No.10 C, DLF Cyber City, DLF Phase-II, Gurgaon, Haryana - 122 002 Ph.: 0124 - 4885560 / 66 / 77; Fax: 0124 - 4283133; Toll Free: 1800 11 4242; E-mail: query.dispatch@fiitjee.com, website: www.fiitjee.com

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Nearest relative / Guardian Address (to be contacted in case the student is not available at the above mentioned address):

Pin : Ph. (Res.) with STD Code : Mobile No. :

Name of the School

(studying or passed)

: : :

Name of the Principal School Address

Pin : Phone No.:

Details about your Parents:

Particulars
Name Qualification Occupation Designation Company Name Company / Office Address

Father

Mother

Company / Office Tel. No. Mobile No. E-mail (in Block Letters) Annual Income

FIITJEE Limited, 1st Floor, Building No.10 C, DLF Cyber City, DLF Phase-II, Gurgaon, Haryana - 122 002 Ph.: 0124 - 4885560 / 66 / 77; Fax: 0124 - 4283133; Toll Free: 1800 11 4242; E-mail: query.dispatch@fiitjee.com, website: www.fiitjee.com

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Test Centres$ for All India Test Series (AITS) for JEE (Main & Advanced) (only one centre can be opted): Delhi (South), Delhi (North-West), Delhi (East), Delhi (Dwarka), Delhi NCR (Faridabad), Delhi NCR (Ghaziabad), Delhi NCR (Gurgaon), Delhi NCR (Noida), Agra, Ahmedabad, Ajmer, Allahabad, Amritsar, Aurangabad, Bangalore, Bareilly, Bathinda, Bhagalpur, Bhilai, Bhopal, Bhubaneswar, Bokaro, Chandigarh, Chennai, Dehradun, Dhanbad, Durgapur, Gaya, Gorakhpur, Guwahati, Gwalior, Hisar, Hyderabad, Indore, Jabalpur, Jaipur, Jammu, Jamshedpur, Jhansi, Jodhpur, Kanpur, Karnal, Kharagpur, Kochi, Kolkata, Kota, Lucknow, Ludhiana, Meerut, Mumbai (Andheri), Mumbai (Chembur), Mumbai (Kandivali), Mumbai (Thane), Muzaffarpur, Nagpur, Patiala, Patna, Pune, Ranchi, Rohtak, Roorkee, Rourkela, Shaktinagar NTPC, Siliguri, Thrissur, Trivandrum, Udaipur, Ujjain, Vadodara, Varanasi, Vijayawada & Visakhapatnam.
$ Above are the Test Centres for All India Test Series for JEE (Main & Advanced) only. (for centres of Concept Strengthening & Analysis Program (CSAP), please contact your nearest FIITJEE Centres.)

Note: All India Test Series (One Year & Two Year) is also available by Correspondence
(All the Test Papers to be received & attempted at your home.)

Course Fee payment details :

Demand Draft No. Drawn on Bank Dated Amount

Check List (Please tick in the box): 1. Photocopy of X / XII Board Marksheet* VIII school final exam marksheet* (for Junior Rankers Study Material) 2. Colour Photographs (3 Passport Size & 1 Stamp Size) 3. Demand Draft for Course Fee
* In case of claim for scholarship, marksheet / certificate of Scholastic Achievement is to be attested by the past or present School Principal.

Note 1: Note 2: Note 3: Note 4: Note 5:

Fee of any program is not refundable at any stage. All India Test Series is part of Rankers Study Material. You need not enrol for it separately in case you are enrolling yourself for Rankers Study Material. Please write your name behind your Photograph and your name & address behind the Demand Draft. The Demand Draft for course fee for all the above mentioned JEE programs should be in favour of "FIITJEE Limited - TS, RTPF, GMP A/c" payable at New Delhi. Photocopy of this form can also be used.

Place: ______________ Date: ______________

(Signature of the Student)

(Signature of Parent / Guardian) Name _______________________________________________ Relationship with the Student____________________________ Mobile. No. of Parent / Guardian _________________________

FIITJEE Limited, 1st Floor, Building No.10 C, DLF Cyber City, DLF Phase-II, Gurgaon, Haryana - 122 002 Ph.: 0124 - 4885560 / 66 / 77; Fax: 0124 - 4283133; Toll Free: 1800 11 4242; E-mail: query.dispatch@fiitjee.com, website: www.fiitjee.com

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For JEE (Advanced), 2013

I am interested in enrolling for (Tick the appropriate box) All India Test Series for JEE (Advanced) Last date to receive completed application

21st April, 2013

For JEE (Main & Advanced), 2014 (for Class XII & XII Pass)
I am interested in enrolling for (Tick the appropriate box) Rankers Study Material (One Year Version) Last date to receive completed application

31st August, 2013

One Year All India Test Series

14th October, 2013

One Year All India Test Series (By Correspondence)

21st October, 2013

For JEE (Main & Advanced), 2015 (for Class XI)

I am interested in enrolling for (Tick the appropriate box) Rankers Study Material (Two Year Version) Last date to receive completed application

20th September, 2013

Two Year Integrated All India Test Series

18th November, 2013

Two Year Integrated All India Test Series (By Correspondence)

25th November, 2013

For students of class IX aspiring to excel in IX, X, Jr. Science Olympiad / Math Olympiad & Foundation JEE (Main & Advanced) / KVPY / NTSE / Other Competitive Exams
I am interested in enrolling for (Tick the appropriate box) Jr. Rankers Study Material Last date to receive completed application

20th September, 2013

FIITJEE Limited, 1st Floor, Building No.10 C, DLF Cyber City, DLF Phase-II, Gurgaon, Haryana - 122 002 Ph.: 0124 - 4885560 / 66 / 77; Fax: 0124 - 4283133; Toll Free: 1800 11 4242; E-mail: query.dispatch@fiitjee.com, website: www.fiitjee.com

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