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Enrollment Number (for ofcial use only)

Enroll m e n t F o r m
(for Classroom / Integrated School Programs)

National Admissions Ofce : FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi - 110 016 Ph. : 011 - 46106000 / 10 / 13 / 15 All India Toll Free No. : 1800 11 4242 Fax : 011 - 26513942 Website : www.itjee.com

Enrollment Form

Classroom / Integrated School Programs


Program Name For Admission in Class 6th LITTLE GENIE - One Year Foundation Program for NTSE & Jr. Science Olympiad-Regular Week Contact Classes LITTLE GENIE - One Year Foundation Program for NTSE & Jr. Olympiads-Sunday Contact Classes Admission to Class VI of FIITJEE World School at Hyderabad For Admission in Class 7th UDAYA Plus - Two Year Integrated School Program for NTSE DAYA UDAYA - Two Year Classroom Program for NTSE-Regular Week Contact Classes DAYA UDAYA - Two Year Classroom Program for NTSE-Weekend Contact Classes DAYA UDAYA - Two Year Classroom Program for NTSE-Sunday Contact Classes DAYA Admission to Class VII of FIITJEE World School at Hyderabad For Admission in Class 8th UDAYA - One Year Classroom Program for NTSE-Regular Week Contact Classes DAYA UDAYA - One Year Classroom Program for NTSE-Weekend Contact Classes DAYA UDAYA - One Year Classroom Program for NTSE-Sunday Contact Classes DAYA Admission to Class VIII of FIITJEE World School at Hyderabad For Admission in Class 9th SUPREME - Four Year Integrated School Program for IIT-JEE Four Year Classroom Program for IIT-JEE - Regular Week Contact Classes Four Year Classroom Program for IIT-JEE - Weekend Contact Classes Four Year Classroom Program for IIT-JEE - Sunday Contact Classes USA UnivQuest - Four Year Integrated School Program (for Admission to US Universities) USA UnivQuest - Four Year Classroom Program (for Admission to US Universities) Admission to Class IX of FIITJEE World School at Hyderabad For Admission in Class 10th Three Year Classroom Program for IIT-JEE - Regular Week Contact Classes Three Year Classroom Program for IIT-JEE - Weekend Contact Classes Three Year Classroom Program for IIT-JEE - Sunday Contact Classes USA UnivQuest - Three Year Classroom Program (for Admission to US Universities) For Admission in Class 11th PINNACLE - Two Year Integrated School Program for IIT-JEE PINNACLE - Two Year Integrated School Program for AIEEE Two Year Classroom Program for IIT-JEE - Regular Week Contact Classes Two Year Classroom Program for IIT-JEE - Weekend Contact Classes T Two Year Classroom Program for IIT-JEE - Sunday Contact Classes Two Year Classroom Program for IIT-JEE Special Weekend Contact Classes Two Year Condensed Classroom Program for IIT-JEE -Regular Week Contact Classes Two Year Condensed Classroom Program for IIT-JEE -Weekend Contact Classes Two Year Condensed Classroom Program for IIT-JEE - Sunday Contact Classes USA UnivQuest - Two Year Integrated School Program (for Admission to US Universities) USA UnivQuest - Two Year Classroom Program (for Admission to US Universities) For Admission in Class 12th One Year Classroom Program for IIT-JEE - Regular Week Contact Classes One Year Classroom Program for IIT-JEE - Weekend Contact Classes One Year Classroom Program for IIT-JEE - Sunday Contact Classes One Year Classroom Program for IIT-JEE - Regular Week + Sunday Contact Classes Special Weekend Classroom Program for IIT-JEE Intensive Contact Program for IIT-JEE Super Rank Enhancement Classroom Program for IIT-JEE Crash Course for AIEEE For Admission After Class 12th One Year Extended Classroom Program for IIT-JEE - Regular Week Contact Classes One Year Classroom Program for IIT-JEE - Regular Week Contact Classes Special Classroom Program (for Ex-FIITJEEians) One Year Classroom Program for AIEEE - Regular Week Contact Classes Intensive Contact Program for IIT-JEE Super Rank Enhancement Classroom Program for IIT-JEE Crash Course for AIEEE 1351 1361 1362 1371 1381 1382 1386 1251 1252 1253 1254 1262 1281 1282 1286 1110 1120 1151 1152 1153 1154 1161 1162 1163 1111 1142 1061 1062 1063 1042 9020 9061 9062 9063 9021 9042 9014 8051 8052 8053 8014 7010 7051 7052 7053 7014 6051 6053 6014 Program Code

Please afx the 2nd passport size colour photograph of the student here

Please afx the 3rd passport size colour photograph of the student here

Please afx the stamp size colour photograph of the student here

Please submit 3 additional photographs with this Enrollment Form

Enrollment Form
Please Note :
v v v

Check the availability of the program at your preferred FIITJEE centre before making a choice. Make a photocopy of this form after lling the required information and before submitting it to FIITJEE. Log on to www.itjee.com/regupdate.htm to update your Contact Details online using Registration Number and web access code printed on your Hall Ticket. Six identical passport size colour photographs of the student (One photograph should be pasted on this page, Two on the previous page and Three photographs should be submitted along with this Enrollment Form). One stamp size photograph (should be pasted on the previous page). Admission Test / FTRE / FTSE / Fortunate - 40 Hall Ticket (in Original). Admission offer letter (in Original). Any one of the following documents :
n n n n

Items required to be submitted along with this form :


v v v v v

Photocopy of School ID card with photograph or Photocopy of last Board or School Marksheet supported by any Identity Proof of student or Photocopy of Transfer Certicate or Bonade certicate issued by the Principal of School with students photograph

Original should be presented for verication at the time of admission.

Test date

: _________________________________________________________ :___________________________________________
Please afx the 1st passport size colour photograph of the student here

Registration Number (as mentioned on the Hall ticket) Study centre Program Name / Code

: _________________________________________________________ : ________________________________________ Code : __________ : ___________________________________________

Scholarship Awarded % (if applicable)


Student Name (in Block Letters) Date of Birth Mailing Address

: _______________________________________________________________ : ________/_______/________________ E-mail ID :___________________________________________ : _______________________________________________________________________________________

________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________ Pin : _________________________________ Contact No (Mobile) Permanent Address (if any) : ____________________________ Land Line (with STD Code) : ___________________________________ : _______________________________________________________________________________________

________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________ Pin :_________________________________ Contact No. (Mobile) : ____________________________ Land Line (with STD Code) : ___________________________________

School/College Last Attended / Presently Attending : _____________________________________________________________________ Address : ______________________________________________________________________________________

_________________________________________________________________________________ Pin : _________________________________ (a) Fathers Name Occupation : Business : _____________________________________ Qualication : ___________________________________ Govt. Service Pvt. Service Others (please specify) : __________________________

Name of the Company / Ofce Nature of Business / Job Department Ofce/Business Address

: _______________________________________________________________________________________ : _____________________________________ Designation : ___________________________________ : ________________________________ Contact No (ofce) : ____________________________________ : ______________________________________________________________________________________

_________________________________________________________________________________ Pin : ________________________________ E-Mail ID (b) Mothers Name Occupation : Business : ________________________________________ Mobile No : __________________________________ : _____________________________________ Qualication : ___________________________________ Govt. Service Pvt. Service Others (please specify) : __________________________

Name of the Company / Ofce Nature of Business / Job Department Ofce/Business Address

: _______________________________________________________________________________________ : ___________________________________ Designation : _____________________________________ : ________________________________ Contact No (ofce) : ____________________________________ : ______________________________________________________________________________________

_________________________________________________________________________________ Pin : ________________________________ E-Mail ID : ________________________________________ Mobile No : __________________________________


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Enrollment Form

(c) Details of the Local Guardian reference (Mandatory if the student is joining as a hosteller)
Local Guardians Name Occupation : Business : ________________________________________________ Qualication : ________________________ Govt. Service Pvt. Service Others (please specify) : __________________________

Name of the Company / Ofce Nature of Business / Job Department Ofce/Business Address

: _______________________________________________________________________________________ : _________________________________________ Designation : _______________________________ : ________________________________ Contact No (Ofce) : _________________________________ : _______________________________________________________________________________________

_________________________________________________________________________________ Pin :_________________________________ E-Mail ID Mailing Address : ________________________________________ Mobile No : __________________________________ : _______________________________________________________________________________________

________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________ Pin: _________________________________

(d) Details of the Sibling(s)


1. Name Class studying in

(if applicable)

: _______________________________________________________________________________________ : ___________________________ Enrollment No. (if enrolled with FIITJEE) :_________________________

2.

Name Class studying in

: _______________________________________________________________________________________ : ___________________________ Enrollment No. (if enrolled with FIITJEE) :_________________________

3.

Name Class studying in

: _______________________________________________________________________________________ : ___________________________ Enrollment No. (if enrolled with FIITJEE) :_________________________

Details of the examination(s) of the class last passed / currently studying


Name of the Examination(s) Board Year of passing / appeared Total Aggregate % (PCM) / (Science + Math) %

Fee Details :

Fee Plan opted (): Fee Plan Code


( (please refer course fee Annexure) ref

II

III

: _______________________________________

Detail(s) of Demand Draft(s) / Pay Order(s) S. No.


1 2 3 4 Total

Instrument Number

Dated

Issuing Bank & Branch

Amount

Enrollment Form

Detail(s) of Post Dated Cheques (Only Local / Payble at par cheques will be accepted) S. No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Total

Instrument Number

Dated

Issuing Bank & Branch

Amount

Students Signature Name : _________________________________ Date : __________________________________ Place : __________________________________

Signature of Father / Mother / Legal Guardian Name : _________________________________ Date : __________________________________ Place : __________________________________

Important Information for Students (and their parents / legal guardians)


1. Before taking admission each candidate, his/her parents & legal guardians are required to (a) Go through the FIITJEE leaet/brochure/information booklet, word of advice, selection letter & website thoroughly. Other than these no other verbal assurance of any kind is given by FIITJEE. (b) It is advised that student undergoes a comprehensive Medical Examination to ensure that he/she is physically & mentally t to take the rigorous for preparing for a competitive exam including but not limited to IIT-JEE, AIEEE etc. as the case may be. (c) Meet few FIITJEE students successful in IIT-JEE / NTSE / AIEEE etc & learn what made them successful. What was the contribution of FIITJEE in their success? Also meet a few FIITJEE students not successful in IIT-JEE / AIEEE /NTSE & learn why they could not qualify IIT-JEE / AIEEE / NTSE. We highly advise that you also talk to non- FIITJEE students both successful in IIT & the unsuccessful ones, to form a clear opinion regarding what a coaching institute can do for you. Please do not take admission at FIITJEE if you think FIITJEE is not the best for IIT-JEE coaching.
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Enrollment Form
An intelligent student having aptitude & analytical skills for IIT-JEE / NTSE etc has to have self study for at least 3 hrs. for every hour taught at FIITJEE. Needless to say if you have not been a highly analytical student you have to put in even greater efforts. IIT-JEE is a different exam where you will feel lost if you do not focus on fundamentals and / or you do not develop / have high analytical skills. Any amount of effort will be in vain without high analytical skills. Admission at FIITJEE does not mean that you have high analytical skills. FIITJEE teachers will guide you in such a way that you can improve your analytical skills tremendously, whether it happens or not will depend upon you. The only way to improve your analytical skills & your chances to get through IIT-JEE/NTSE etc is to solve each & every problem in FIITJEE assignments yourself. You may have to make several attempts & even go back to your basics to refresh them to solve a particular problem. It is this intensity & quality of effort which will help you develop good analytical skills. In the end, remember while anyone can appear in IIT-JEE or pretend to prepare but only the ones who walk the right path succeed. FIITJEE has no magic potion to make you successful. Besides, coping up with school / college & IIT-JEE studies will challenge every bit of your mental & physical energies. 2. FIITJEE starts making arrangements of infrastructure, faculty & other resources about 6 months before commencement of nancial year. FIITJEE admits students as per its capacity plans, (subject to unforeseen circumstances & usual organizational risks) therefore each student taking admission has to pay complete fee under all circumstances i.e. even if he/she discontinues for any reason whatsoever or parents/ guardians be transferred. Not all students who sit in our admission test are offered admission therefore you & parents have to be very sure before taking admission as you have to pay complete fee under all circumstances. Once a class starts FIITJEE does not admit any students. Therefore, any vacancy created by a student leaving cannot be lled up. Since FIITJEE has to source infrastructure, faculty etc. in advance, loss of fees of students leaving after taking admission will compel the institute to enhance fees for next batch of students which is unfair to them. Therefore, students/parents must clearly understand this important aspect and take admission only if they are fully satised.

Kindly do not take admission at FIITJEE, if the following declarations are not agreeable to you

Declaration:
1. 2. I hereby declare that the information furnished on the enrollment form etc. is correct to the best of my knowledge and belief. I/we clearly understand that FIITJEE on completion of topics to be covered by FIITJEE in XI as per its plan will do goal refocusing for all Two Year Classroom Program students including PINNACLE program students to help each student achieve maximum possible success. This means that some students based on their performance, may have to predominantly focus on exams other than IIT-JEE. If any discrepancy in this information or otherwise is found at any stage of my association with FIITJEE, any action deemed t by FIITJEE including my expulsion from the institute may be taken against me. In such a case I or my parents/guardian shall have no claim for any type of compensation/refund of fees. I am taking admission in FIITJEE with the consent of my Father/Mother/Legal Guardian and after being satised in all respects. I understand that if I fail to complete/submit all remaining formalities/documents, if any, upto two days prior to the start of the classes, unless otherwise allowed in writing, I shall not be allowed to attend the classes till the needful is done, and in that case I or my father / mother / legal guardian shall have no claim for refund of fees or any compensation, including in studies. I understand that if I leave the institute before completing the full course for any reason whatsoever, including transfer of my father / mother / legal guardians / ill health of myself or any other member of the family or my admission in any institute / course / engineering college etc., or my studentship is cancelled because of misconduct etc. I or my father/mother/legal guardian shall have no claim for refund of fees. In addition to the above, I understand without any ambiguity that the fee once paid is not refundable at all, whatever the reasons be, nor is it adjustable towards any other existing courses at FIITJEE or any yet to be launched nor towards the fee of any other existing or prospective student. I will follow all rules & regulations of the associate school of FIITJEE Limited allotted to me in principle. And I agree that decision of FIITJEE management relating to all Terms & Conditions, Rules & Regulations of the associate school will be nal and binding in all circumstances and situations, whatsoever. It is understood that this admission is valid only for the course and the duration to which I am taking admission and I/We (the student and the parents) shall not claim/request for adjusting the fees to any other course or duration. I/We undertake that the course material whatever is given to the student during the course of study at FIITJEE, shall not be given to any one else for any purpose whatsoever. I know that registered ofce of FIITJEE Ltd. is situated at New Delhi. I promise to abide by all rules and regulations of FIITJEE declaration, in letter and spirit. In the event of any dispute regarding the interpretation of clauses of enrolment form or any claim etc. arising out of taking the admission in FIITJEE Ltd., the matter shall be referred to the Sole Arbitrator appointed by the Management of FIITJEE Ltd. The decision of the arbitrator shall be nal & binding on both parties. The arbitrator so appointed shall not be incapacitated for reasons of their being the employee or an associate of FIITJEE Ltd. or its sister concern, and for reasons of having any prior linkage with the company. The venue of Arbitration shall be Delhi / New Delhi only. Subject to clause 13 above, I/We (the student and the father/mother/legal guardian) understand that in case of any legal dispute, the jurisdiction will be an appropriate court/forum in Delhi/New Delhi only and I shall not take recourse to such an action in any other court/forum any where else. In case I do, I shall inform the relevant court/forum regarding this jurisdiction constraint. I/We have fully satised ourselves with regards to quality and excellence of teaching at FIITJEE from all available information/sources and have decided to study only at FIITJEE. I/We wish to pay the entire fees in Fee Plan I / Fee Plan II / Fee Plan III option of our own sweet will and convenience without any pressure/coercion from any one. I/We agree to give a copy of the JEE Admit Card of the student by 25th March of the concerned JEE year to FIITJEE.

3.

4. 5.

6.

7.

8.

9. 10. 11. 12. 13.

14.

15.

16.

Enrollment Form
17. I/We understand that (in case of scholarship student), if we fail to give the JEE admit card by 25th March of the concerned JEE year, FIITJEE will have the right to discontinue the scholarship and/or recover the scholarship with interest and the student / parents / legal guardian will have no objection for the same.

18. I/We fully understand that FIITJEE is giving the scholarship because the student is expected to bring laurels to FIITJEE and will spread good word of mouth among the students. I/We will fully cooperate to achieve this objective including giving the JEE Admit Card before 25th March of the concerned JEE year and signing the letter of appreciation lauding FIITJEE efforts. 19. 20. 21. 22. I/We (student and the parents) declare that FIITJEE will have sole claim over the outstanding academic performance of the student and further agree to give a letter of appreciation to FIITJEE for the outstanding result. I have read the above as well as the current FIITJEE Brochure carefully and have understood it clearly. I have also received a copy of the above and FIITJEE Brochure for my future reference and timely compliance. I / We, the parent/guardian and/or the student, hereby severally and jointly declare unambiguously that I/we have read and understood all the clauses contained in the Declaration and agree to abide by them without any reservation or ambiguity. I / We further declare that the above named student is taking admission in the program as mentioned on page 3 having considered everything material, on his own sweet will after giving due consideration to rigors of time, distance and studies ahead and with the permission of the father/ mother/legal guardian without any coercion from any side. Further I/We understand that the student is required to work hard to attain the average standard of the batch allotted in order to cope up with studies and put in extra efforts if lagging behind in any subject/topic. I / We further undertake to ensure that cheques/drafts including post dated cheques if any given by us will be honored by our bankers. In the event of these cheques/drafts being dishonored, FIITJEE is at liberty to initiate any action against us including legal proceedings to include invoking provisions of section 138 of Negotiable Instruments Act. I have read the above carefully and have understood it clearly. I have kept a photocopy of all the pages of this enrollment form including this declaration and Annexures A, B, C & D for my future reference and timely compliance.

23.

24.

Additional declaration for Integrated School Program Students only :


25. I / We (Student and the parent) am/are joining FIITJEEs Integrated School Program only after satisfying myself / ourselves about the structure of program. Ill fully abide by the rules and regulations of the school. I also understand that in the event I am expelled from the school on any disciplinary ground Ill raise no claim from FIITJEE for any academic and/or nancial loss including course fee.

Students Signature Name : __________________________________ Date : ___________________________________ Place : ___________________________________

Signature of Father / Mother / Legal Guardian Name : __________________________________ Date : ___________________________________ Place : ___________________________________

(To be struck off, if not applicable) As my father / mother / legal guardian do(es) not reside in Delhi and I have no local guardian. I own all responsibility on their / his / her behalf.

Date : _________________________________ Place : _________________________________

Students Signature : ________________________________ Name : _______________________________________________

(Declaration to be given if the Enrolment form is not signed by the Father/mother/legal guardian at the time of admission) I have received an extra copy of this Enrolment Form, which I shall send to my father/mother/legal guardian and submit to FIITJEE within 15 days with his/her signatures. If I fail to do so unless a further relaxation has been given by the FIITJEE authorities in writing, my admission shall be liable to be cancelled and I or my father/mother/legal guardian shall have no claim for refund of fees or any other compensation of any type.

Date : _________________________________ Place : _________________________________

Students Signature : _________________________________ Name : ________________________________________________

Instruction : After lling-up annexure A, B, C, D please retain photocopy of the same before submitting at the FIITJEE Checklist : 1. Demand Draft(s) / Pay Order(s) for the fee. 3. Enrolment Form duly lled in. 5. Colour Photographs (a) Passport size (Six) (b) Stamp size 2.5 x 2 cm. (One)
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2. Local / at par post dated cheque(s) 4. Annexure A to D

Enrollment Form

Annexure A PARENT DATA SHEET


(CONFIDENTIAL) Dear Parent /Guardian The right and accurate feed back of your ward/student will give us an opportunity to understand the student better which will help us in providing better support & education. This information will be condential.

1. 2. 3. 4.

Name of the Student Fathers/Guardians Name Relation with Student

: ______________________________________________________________________________ : ______________________________________________________________________________ : ______________________________________________________________________________

How would you rate the student in the following characteristics ? ( the appropriate)
Excellent Sincerity Leadership Imagination Emotional stability Ability to work with others Ability to work hard Perseverance Good Average Below Average Low Unknown

6. 7.

What is the students class rank? : ____________________________________________________________________________ Some gifted individuals make mediocre scholastic records. Is the students record an accurate index of his/her capabilities? Yes / No If no, state why? : ______________________________________________________________________________

8. 9.

What is the students biggest weakness? : ______________________________________________________________________ Have there been any major changes in the students attitude towards studies till now at any time, if so illustrate, when and why?
(You may attach a blank page if required.)

10. What career do you feel shall be best for the student? : ___________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 11. Please mention any other information relating to the student, which help make FIITJEE understand the student better. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 12. My son / daughter / ward has a sound moral character & sense of responsibility. He/she also has good physical and mental health to successfully cope up & complete his/her studies at FIITJEE and fulll all terms & conditions.

Father / Mother / Legal Guardians Signature

Date : _________________________________ Place : _________________________________

Enrollment Form

Annexure B TERMS & CONDITIONS FOR POST DATED CHEQUE(S)


I understand that if my son/daughter/ward withdraws from the Program to which he/she has been admitted at any point of time or does not attend the Program and thus the seat given to him/her is rendered vacant, the same will not/can not be lled up by any other candidate and a vacancy created in the batch due to withdrawal of a student after the starting of classes or up to 2 days prior to the same cannot be lled in any case, therefore I understand that FIITJEE shall suffer irreparable losses in case of non-payment of remaining fee of the installment plan, hence it will be unethical not to honor the Post Dated Cheque(s).I have opted for installment fee plan and have submitted the Post Dated Cheque(s) as per the details give below. I agree that, I will make arrangement, for below stated Post Dated Cheque(s), to get honored, and will keep sufcient funds on or before the due date for the same. Detail(s) of Post Dated Cheque(s) S. No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

A Afx one self attested pass passport sized photograph of the person issuing Post Dated Cheque(s) i.e. parents / guardian

Cheque No.

Dated

Issuing Bank

Fee Amount

S. Tax Amount

Total Amount

I further agree, to get above Post Dated Cheque(s) cleared, even if, my son/daughter/ward discontinues studies at FIITJEE, irrespective of any reasons. I am signing the above declaration in good mental/physical health. I have satised myself about FIITJEE. The necessary Enrolment-Forms, including this form was received by me several days before the actual date of signing to enable me to understand the implications of taking admission at FIITJEE. I have taken expert opinion regarding matters which were not clear to me and I am satised.

Signature of the Student Name : ____________________________________________________ Enrolment Number (for ofce use only) : __________________________ Date : _____________________________________________________

Father / Mother / Legal Guardians Signature {Who has issued the cheque(s)} Name : ______________________________________ Address : ____________________________________

I have retained photocopy of this document for my reference before submitting it at FIITJEE. Date : _________________________________ Place : _________________________________
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Father / Mother / Legal Guardians Signature Name : ______________________________________

Enrollment Form

Annexure C CONSEQUENCES OF DISHONOUR OF POST DATED CHEQUE(s)


I understand that non-clearance of any of the Post Dated Cheque(s), submitted for payment of fees (on installment basis) as mentioned in the Enrolment-Form and annexure B is punishable under Sec. 138 (B) of the Negotiable Instrument Act. I understand that FIITJEE shall be entitled to proceed and initiate appropriate legal action against me, to recover the amount of the Post Dated Cheque(s) along with the legal expenses and out of pocket expenses incurred by FIITJEE. In case any of my Post Dated Cheque(s) bounces for any reason whatsoever, I undertake to submit a DD/Pay-Order in favour of FIITJEE Ltd. payable at New Delhi, within four days of the bouncing of the Cheque(s) at my bank, together with Rs. 500/- (Rupees ve hundred only) as default money alongwith late payment of Rs. 50/- (Rupees fty only) per day upto 10(Ten) days from the due date of payment of instalment after which my son/daughter/ward shall be debarred from classes without any further notice and I shall have no claim for refund of fees or any support in studies besides Legal action inter alia action under Section 138 (B) of the Negotiable Instrument Act may be initiated against me/us.

Signature of the Student Name : ____________________________________________________ Enrolment Number (for ofce use only) : __________________________ Date : _____________________________________________________

Father / Mother / Legal Guardians Signature {Who has issued the cheque(s)} Name : ______________________________________ Address : ____________________________________
_____________________________________________ _____________________________________________

I have retained photocopy of this document for my reference before submitting it at FIITJEE.

Date : _________________________________ Place : _________________________________

Father/Mother/ Legal Guardians Signature Name : ______________________________________

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Enrollment Form

Annexure D
Kindly do not take admission at FIITJEE if the clauses of the declaration on the enrolment form along with the following amendment is not agreeable to you. Name of the Student : _________________________________________________________________________________________ Name of the Father / Parent / Guardian: ___________________________________________________________________________ Residential address : ___________________________________________________________________________________________ Specically Declaration 7 is being reproduced hereunder : Declaration 7 : In addition to the above, I understand without any ambiguity, that the fee once paid is not refundable at all, whatever the reasons be, neither is it adjustable towards any other existing courses at FIITJEE or any yet to be launched nor towards the fee of any other existing or prospective student. Declaration : I/We the Father/Mother/Legal Guardian and / or the student hereby severally and jointly declare that I / we have read and understood all the clauses contained in the Declaration on the Enrolment Form together with the above amendment and agree to abide by them without any reservation or ambiguity. I/We further declare that the above named student is taking admission in the ____________________________________________ ___________________________________________________(course opted for) having considered everything material and on his own sweet will and with the permission of the Father/Mother/Legal Guardian without any coercion from any side.

Signature of the Student Name : ____________________________________________________ Enrolment Number (for ofce use only) : __________________________ Date : _____________________________________________________

Father / Mother / Legal Guardians Signature Name : ________________________________________ Address : _______________________________________


________________________________________________

I have retained photocopy of this document for my reference before submitting it at FIITJEE.

Date : _______________________________ For Ofce use only

Place : _____________________________

Father/Mother/ Legal Guardians Signature

Check list for the Accountant / Admission Coordinator.


v v v

Name of the Accountant / Admission Coordinator. The Application form is complete in all respect with Annexure A,B,C and D duly signed by the student and the parent. The details of the scholarship offered. o Cash scholarship (If any) : _______________________________________________________________________________ o Fee Waivers offered (If any) : ___________ % on ____________________________________________________ ground. o Hostel fee waiver (If any) : ______________________________________________________________________________

v v v v v v v

The certicates pertaining to scholarship are attached. 6 passport size and one stamp size photograph are attached. Late payment charges / Admin. charges duly calculated and collected. The fee charged has been duly matched and veried with the fee brochure. Signatures on PDCs and on Annexure B and C are same. Is the student joining as a Hosteller? If yes details of the Local guardian are provided. The student has been offered the admission after selection in Admission test only.

Declaration by the Accoutant / Admission Coordinator. I have veried the entire enrollment form and checked all the points mentioned above. The Enrollment is recommended.

Date : _______________________

Place : _________________________
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Signature of the Account / Admission Coordinator

National Admissions Ofce : FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi - 110 016 Ph. : 011 - 46106000 / 10 / 13 / 15 All India Toll Free No. : 1800 11 4242 Fax : 011 - 26513942 Website : www.itjee.com
CONTACT NO. 011 - 46106000 /10 /13 /15 011 - 45634000, 45634003 011 - 43002500, 42448484, 42448485 011 - 45616600, 45616601 011 - 47064000, 47064009 011 - 45769405 0124 - 4628400, 09871091545 0120 - 3105005, 4754800 0129-4174582, 09910059641 0183 - 3203344, 2501686 080 - 41135682, 41148491 0674-2392022, 09583165026 0788 - 3205808, 4035204, 09329733322 0755 - 4253355, 4253455 06542 - 325511 /20, 233775 /76 0172 - 3010043 /44, 5085170 Patna FIITJEE Towers, No. 3, 1st Lane, Nungambakkam High Road, Chennai - 34 044 - 43937100 044 - 42859701, Mobile / SMS : 09677177717 /18 /19 044 - 43950450, Mobile / SMS : 09677177713 09677177712 0326 6550857, 09334508761 0343-2542643, 09804750283 040 - 66777000 /01 /02 /03 040 - 64569509, 66757890 /91 040 - 64601123 Pune 3rd Floor, A-Wing, Vega Centre, Swargate, Shankar Sheth Road, Pune Courtesy : Gyan Ganga Educational Academy, 12 K. M., Vidhan Sabha Marg, Raipur - 493 111 7th Floor, Hari Om Tower, Circular Road, Ranchi 020 - 41418686, 09561832696 0788 - 3205808, 4035204, 09329733322 0651 - 2563188 /89 /90 CONTACT NO. 0731 - 4274702 /63, 4044447, 09981764461 0141 - 5181883, 09314328973

CENTRE Delhi (South) Delhi (Punjabi Bagh) Delhi (East) Delhi (Janak Puri) Delhi (Rohini) Delhi (Dwarka) Gurgaon (Delhi NCR) Noida (Delhi NCR) Faridabad (Delhi NCR) Amritsar

ADDRESS FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi - 16 31, 32, 33, Central Market, West Punjabi Bagh, New Delhi - 26 5th Floor, Roots Tower, District Centre, Laxmi Nagar, Delhi - 92 B-1, 623, 2nd Floor, At District Centre Crossing, Janak Puri, New Delhi - 58 367, Kohat Enclave, 2nd & 3rd Floor, Near Kohat Metro Station, Pitampura, New Delhi - 34 2nd & 3rd Floor, Manish Metro Plaza - V, Plot No. 4, Pocket - 6, Sector -12, Dwarka, New Delhi - 75 Building No. 128, Institutional Area, Sector 44, Gurgaon B-4, Near AXIS Bank, Sector - 16, Noida Sector - 15 - A Market, Near Vidya Mandir School, Ajrounda Chowk, Faridabad 3rd Floor, SCO: 31, District Shopping Centre, B Block, Ranjit Avenue, Amritsar 113/114, 3rd Floor, HTR Chambers, S. C. Road, Opp. Hoysala Hotel, Seshadripuram, Bangalore Bharat Scouts & Guides Complex, Scouts Bhawan, 2nd Floor, C - IX / 8, Unit - 3, Bhubaneswar - 22 Ayushman, 5/9, Priyadarshini Parisar (East), Opp. Supela Thana, G.E. Road, Bhilai - 490 023 48-A, 3rd Floor, Guru Kripa Plaza, Zone II, M.P. Nagar, Bhopal 2nd Floor, B-1, City Centre, Sector-IV, Bokaro Steel City, Bokaro SCO: 321-322, First & Second Floor, Sector 35-B, Chandigarh

CENTRE

ADDRESS 27, 2nd Floor, Scheme No. - 54, PU-3, Opp. Orbit Mall, Commercial Bhamori, A.B. Road, Indore 3 - A, DL Tower, Behind Parishad Bhawan, Opp. Vidya Ashram School, J.L.N. Marg, Jaipur 1st Floor, Vaibhav Multiplex, C-1, C Block, Amrapali Circle, Vaishali Nagar, Jaipur

Indore

Jaipur (J.L.N. Marg) Jaipur (Vaishali)

0141 - 5181886 0512 3010901 /11, 09792333384, 09792333387 033 - 30537576 /77 /78 /79 /80

Kanpur

16/116, Karmin Arcade, Civil Lines, Kanpur

Kolkata (Rabindra Sadan) Kolkata (Ultadanga-Salt Lake) Lucknow

3rd Floor, The Millennium (besides Hotel Hindustan Intl.), A. J. C. Bose Road, Kolkata - 20 VIP Towers, Ground Floor, 80, Golaghata, VIP Road, Ultadanga, Kolkata - 48 Scholars Home, Vipul Khand - 3, Gomti Nagar, Lucknow - 226 010 2nd Floor, Radhakrishna Apartments, Opp. Ideal Book Depot, Vachnalaya Marg, Dadar (West), Mumbai Courtesy : Thakur Vidya Mandir High School & Junior College, Thakur Complex, Kandivali (East), Mumbai Ujagar Complex, Opposite Deonar Bus Depot, Off Sion Trombay Road, Deonar, Chembur, Mumbai Ground Floor, Baba House, Andheri Kurla Road, Off Western Express Highway, Andheri (E), Mumbai B - 500, Second Floor, Vashi Plaza, Plot No. 80 - 81, Sector - 17, Vashi, Navi Mumbai 2nd Floor, Evershine Mall (Prabhat Plaza), Opp M H High School, Station Road, Thane (W) Ginni Building, Plot No - 210 (Opp. Children Trafc Park), Zenda Chowk, Dharampet, Nagpur - 440 010 2nd Floor, Saday Bhawan, Marwari Awas Complex, Fraser Road, Patna

033 - 40221300

0522 - 3067183, 3067185 022 - 32666214, 32911892

Mumbai (Dadar) Mumbai (Kandivali) Mumbai (Chembur) Mumbai (Andheri) Mumbai (Navi Mumbai) Mumbai (Thane)

022 - 32683438

Bangalore

022 - 42704000

Bhubaneswar

022 - 42378100

Bhilai

022 - 41581500

Bhopal

022 - 41617777 0712 - 6600501, 6600502, 08806603888 0612 - 3299798, 2205552

Bokaro

Nagpur

Chandigarh Chennai (Nungambakkam) Chennai (Kilpauk) Chennai (Adyar) Chennai (Sriperumbudur) Dhanbad

175, Poonammallee High Road, Opp. Ega Theatre, Kilpauk, Chennai - 10 New Number 11, 29th Cross Street, Indira Nagar, Adyar, Chennai - 20 Courtesy: Maharishi International Residential School, Santhavelur, Sunguvar Chatiram (Kancheepuram Dist.), Sriperumbudur Tara Apartment , Plot No 2311- 2313, Mouza Saraidhela, Dhanbad A-3, Nandalal Bithi, Beside Income Tax Ofce, City Centre, Durgapur - 713 216 5-9-14/B, Saifabad (Opp. Secretariat), Hyderabad D No : 16-11-477/6/2/2, Sahadeva Reddy Buildings, Lane Beside Sahadevareddy Sweets, Dilsukhnagar - 500 036 H. No. 22-97, Plot No. 1, Opp. Patel Kunta, Huda Park, Vijaynagar Colony, Kukatpally

Raipur

Ranchi (Lalpur) Ranchi (S.O.P., Doranda) Shaktinagar NTPC

Samriddhi Complex, Ground Floor, Near St. Xaviers School, S.O.P, Doranda, Ranchi - 834002 Courtesy : Employee Development Centre, Hostel No.3, Shaktinagar NTPC, Distt.: Sonebhadra (UP) 2nd & 3rd Floor, Gauri House, (Near Manisha Chokri), Old Padra Road, Vadodara

0651 - 2563187

05446-232366, 232372

Durgapur Hyderabad (Saifabad) Hyderabad (Dilsukhnagar) Hyderabad (Kukatpally)

Vadodara

09099213777 0542 - 6550103 /04 /05 /06 /07 /08 /09 0891 - 2555501, 2555502

Varanasi

B-38 / 1 K, Mahmoor Ganj, Varanasi

Visakhapatnam

47-7-47, Plot No. 87, Opp. Nehru Bazaar, Dwarkanagar, Visakhapatnam