APPLICATION NUMBER :

221091
DETAILS OF CANDIDATE

Date : 29/10/2011

Name of the Candidate (As in 10th Class Certificate) : Nationality : Indian No Person with Disablity :

NANDINI SHARMA Gender : Female Scribe Required : Category : GEN Date of Birth : 30/04/1991 Relationship : Father

Name of Father/Mother/Guardian:

MR. MANMOHAN KRISHAN SHARMA CHOICE OF TEST PAPER [S]

No. of Test Paper[s] Applied :

Session 1 : [PH] Physics CHOICE OF CITIES/TOWNS FOR THE TEST

Session 2 : [MA] Mathematics

Choice of Cities/Towns for the Test

First Choice : [302] Delhi East

Second Choice : [301] Delhi Central

DETAILS OF QUALIFYING EXAMINATION Qualifying Degree : B.Sc Qualifying Examination Passed : No Year of Qualifying Exam : CGPA (out of 10) : DETAILS OF DEMAND DRAFT DD No. 606546 Nationalised Bank Drawn On Punjab National Bank SOURCE OF INFORMATION OF JAM 2012 I found out about JAM 2012 through : Newspaper Advertisement DETAILS OF CONTACT ADDRESS Name :
(DO NOT STAPLE)

Percentage of Aggregate Marks :

Other

Date 19/10/2011

Amount 1100

The Employment Newspapers

NANDINI SHARMA C-89,F-4,SURYA APARTMENTS RAMPRASTHA, GHAZIABAD

Address :

Paste a Front Facial High Contrast Recent Colour photograph (3 cm X 4 CM) without any signature or attestation

UTTAR PRADESH

State :

Uttar Pradesh

Pin Code : 201011 Email : Phone : nandini_304@yahoo.com 09818007089

Mobile No : 09717752222 DECLARATION BY THE CANDIDATE: FULL SIGNATURE OF THE CANDIDATE(IN BLACK INK BALL-POINT PEN) I hereby declare that all the particulars stated in this Application form are true to the best of my knowledge and belief. I have read the information Brochure and I shall abide by the terms and conditions therein. In the event of suppression or distortion of any fact made in this application form, I understand that I will be denied the opportunity to appear in the JAM 2012, and if already appeared/ selected/ admitted, my admission/ degree acquired is liable to cancellation. Place : Date :
FULL SIGNATURE OF THE CANDIDATE (IN BLACK INK BALL-POINT PEN)

221091

BY REGISTERED POST/SPEED POST APPLICATION FORM

PAPER CODE EXAM CITY PH 302 MA 301 To ORGANIZING CHAIRMAN, JAM 2012 INDIAN INSTITUTE OF TECHNOLOGY BOMBAY From
NANDINI SHARMA

POWAI, MUMBAI PINCODE 400076

C-89,F-4,SURYA APARTMENTS RAMPRASTHA, GHAZIABAD UTTAR PRADESH

APPLICATION NO

221091
PINCODE 201011

Uttar Pradesh

CHECK-LIST
1.Cut the above address slip along the dotted line and paste the address slip on the envelope containing your completed application form with your photo pasted on it and your two signatures. You must write your name and application number at the back side of the photograph before pasting it within the box provided in the application form. 2.You must enclose the attested copies of all relevant certificates (SC / ST / PD / Affidavit for change of name, if applicable) and the demand draft in the envelope. 3.Send the envelope by speed / registered post only. Application sent by courier will be rejected.