TO BE ENCLOSED WITH THE

PAY-IN-SLIP BANK’S COPY PAY-IN-SLIP CANDIDATES’S COPY PAY-IN-SLIP

APPLICATION
KVPY – 2009 KVPY – 2009 KVPY – 2009
INDIAN INSTITUTE OF SCIENCE INDIAN INSTITUTE OF SCIENCE INDIAN INSTITUTE OF SCIENCE
BANGALORE – 560 012 BANGALORE – 560 012 BANGALORE – 560 012

State Bank of India State Bank of India State Bank of India

Payable at all Branches of SBI in India Payable at all Branches of SBI in India Payable at all Branches of SBI in India

Branch Name and Address: Branch Name and Address: Branch Name and Address:

Paid into the credit of Administrative Executive, Paid into the credit of Administrative Executive, Paid into the credit of Administrative Executive,
KVPY, IISc., Bangalore – 560 012 KVPY, IISc., Bangalore – 560 012 KVPY, IISc., Bangalore – 560 012

SB A/C No. 10270577392 SB A/C No. 10270577392 SB A/C No. 10270577392

Rs. Rs. Rs.
Rupees………………………… Rupees………………………… Rupees…………………………

Application No. Application No. Application No.

………………………………. ………………………………. ……………………………….
Name and ………………………………. Name and ………………………………. Name and ……………………………….
address of ………………………………. address of ………………………………. address of ……………………………….
the candidate ………………………………. the candidate ………………………………. the candidate ……………………………….
………………………………. ………………………………. ……………………………….
………………Pin…………… ………………Pin…………… ………………Pin……………

Application Processing fee: Application Processing fee: Application Processing fee:

Tick as applicable Tick as applicable Tick as applicable
(last date to remit the money – 10/09/09) (last date to remit the money – 10/09/09) (last date to remit the money – 10/09/09)
General Category SC/ST Category General Category SC/ST Category General Category SC/ST Category
(a) Rs. 200/- □ (a) Rs. 100/- □ (a) Rs. 200/- □ (a) Rs. 100/- □ (a) Rs. 200/- □ (a) Rs. 100/- □
(b) Bank charges if (b) Bank charges if (b) Bank charges if (b) Bank charges if (b) (b) Bank charges (b) (b) Bank charges
any any any any if any if any
Signature of the Signature of the Signature of the
Depositor Depositor Depositor

Signature of the Signature of the Signature of the

Cashier Cashier Cashier

Bank Stamp with Bank Stamp with Bank Stamp with

date date date