APPLICATION FORM (for Official use ony) Rogstraton No, Alois Form Checked by: Employee Code: Siorature ate Please fill this Form with a Black | Blue pen in BLOCK Letters only Application Form No. F ‘Are you already Enrolled | Registered in FIITJEE ? tyes, please provide the following info below: 8) Enrollment Number Registration Number b) Stucents 1D Mobile Number] (ONT STAPLED 4. Details about the Student: Poste your a) Name of the Student recent passport size (ODMMYYYY) (c}Gerderv) Male [| Femaie [| | ter Photearaph ners by Date of inn 18) Lest Annual Exam / Board Exam Aggregate Marks (2) (© Nationality Carry one addtional 0 photograph for Hall Ticket ‘Aadhar number ofthe student (pease attach a copy ofthe student's Aadhar Cor) — ° Stream you wil pursue afer Class XII {Pease tok (7 Enameerng [| Non-Enginearing: Humanities Fundamental Se Commerce Medical Wotner pe 50 specify 2. Details to be fi in {for Registration Centre, Study Centro, Test Centre & Segment Codes, please refer to point no, 1, 28 3 of relevant Information Booklet (@) Testa ] (b) Regstaion Cente Coue [| (6) Scomant Code oo () Stuy Corvecode [| o) Tet Cenice Cove Oo f) Class” Presently Stucying in the Curent Academe Year (AY) * ior eas Sth 05, cies hf 6 las Tih 9, Class hf 8, Cleat i 8, Css 1M 1, Co wat) Painted (Prine Hal Tekets wil be issued only Hf his Appleation Form is submitted to @ FUTJEE alice In person) 3. Communication Detais st 15, cles 12070112 & Cine 120 Pass 19) (6) How co you want to receve the Hal Tket oO fa} E-Mail IDs ond Mobile Nos a 10 (Please Fn BLOCK Letters Ony) Mode Number Student Motner Uwhatisyourpetenese-nalid C)susear []raner []weve Whatisyourpretanes Metin. C)Suaene Crate Jeane (b} Correspandonce Address (©) Permanent Adress: (Pease mention ony taternt rm - Pin Pin Details about tho Schoo! Presently Studying in Last Attended: {a} Schoo! Name & Adcross City/Town Ph Code Stale To. No. (0) Board (Sehod!'s affiiates to) {c) Your Current Last Class Rankin your Seno! (4) Name of your Sew! Prnepal (2) Name of your Subject Tencner Mathematios Physics Biology chemistry5. Dotails about Parents (in BLOCK Letters only) Fathor’s Legal Guardian Name uaiticaton ceupation Designation tice Name | Adcrese Contact Nos Mother's Name Quaiticaton Occupation Designation tice Name | Adcrese CContaet Nos 6. Details of your Scholastic Achievements in any of these exams (Please tick (y’)& give its details}: wise) | sts nseis| use| kver| olympia sar[ ] others Details 7. Are you taking any specialized Coaching for Competitive Exams (Please tick(/)}: Yes No Since Yea") I Yes, Name of your Coaching instiute Your Overall Rank in your Coaching Institute 8, Details about Your Sibling Name 1 Brother /Sistoy ass presently sting i Name 2 (Brother Sister) Class presently studying in 9. How did you come to know about FIITJEE Programs ? (Please tick\v} Newspaper Adv. Q Socal Media News Paper Insert © Banner’ Poster Website E-Maller Hoardings © Radia © Present Ex FITEE Student Fronds / Relatives © Through FIITJEE Facully ©) if otner source (oiease spect) Declaration by the Student / Parent / Guardian ‘© Hehe eosved en Ine Term & Contos rien ie normaton boot fhe Test Dae merianeagains! Point No 2(8 fs Applicaton For and prea a ‘+ Inve avo cross vores Codes fits natove Pon: Zand understand #aneror occa he reg stron du towrang codes wlohe coneetedbyFITIES {© IsunonoF ITE tcomaetandsendcon-nunicatn internation by SUS, cms, poston the above mentenadconmunicaton deta vane “© Incase astute eappeas in FITIFE Tost his! hr slash (aware) il be sale down by ne sa soa shedas tt hae ny undo sung oer oh 1+ ITIEE reorves hong toot stay conte oherthantheone oped ty susen sutyecto avalabity/constantse sos 1+ Once sticont granted samisen to the hostel he wi at be pernied ow suring he ours the academe session an nol end le made sung mi ‘he Rego Oa FUTIE Lie Re Oh ncaa of slates pret ae sett eave estonia Dam New orbirator se appointee shall nt be neapactaled for reasans other beng he empoyee of FITIEE Lined ar is sser concer and for sesone ofhawng 2° prior inkage Fee Paid Rs. in Cash (D0 Pay Onder No Dates Bank | we hereby deciae thal te information furnished on this Apolcalion Form is correct Io the best of my knowledge and belie Date: (Signature of Studort) (Name of Student) Place: (Signature of Parent / Guardian) (ame of Parent Guardian) National Admissions Office: FITJEE House, 29-A, Kalu Sarai, Sarvap‘ya Vihar, New Di - 110 06. Ph D1t-492864711 73175 Alindia Tol Free No 1800 17-4242 Web: www ijee.com