Auth Code: b18bfcdc2c732579f5fad6a6aaedd19e 1. Candidate Name: Ansari Faheemuddin Naseeruddin 2. Parent/Guardian Name: Ansari Naseeruddin 3.

Date of Birth: 21-11-1990 6. Nationality: Indian 9. First Attempt at JEE: In 2011 12. Enlarged Font Paper Required: No 15. Address: H.No.107 2nd Floor Ashrafiya Manzil Near Rehman Sardar Compound Navi Pada Kalyan Road Bhiwandi Dist Thane Maharashtra 16. PIN Code: 421302 21. Type of Preparation: Self 23. Board of QE: State Board 25. Parents' Educational Background: Neither Graduate 27. Annual Income of Parent/Guardian: Below Rs.1,00,000 22. Place of 10th Class Schooling: City 24. Mother Tongue: Urdu 26. Occupation of Parent/Guardian: Other 3.5 cm x 4.5 cm with the face covering about 75% of the photo 4. Gender: Male 7. Year of Passing 10th Class: 2008 10. Question Paper Language: English 13. Entitled for DS Seat: No 17. Email ID: AFAHEEM90@YMAIL.COM 18. Mobile No: 08237111923 19. Landline No: 08237111923 20. PIN Code of Permanent Residence: 421302 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: GE 8. Year of Passing QE: Passed earlier than 1st Oct 2010 11. Physically Disabled: No 14. Choice of Exam Cities: I. Thane (117) II. Mumbai (110)

DECLARATION BY THE CANDIDATE

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 IIT-JEE 2012 Information Brochure (given on IIT-JEE Website) and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2010 or earlier and neither taken admission nor paid the registration fee at any of the IITs / IT-BHU / ISM-Dhanbad. In the event of suppression or distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the opportunity to appear in IIT-JEE 2012 and if already admitted, my admission / degree acquired is liable for cancellation. I also understand that the decision of the Joint Admission Board regarding my admission to IITs / IT-BHU / ISM-Dhanbad is final and I shall abide by the decision. Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place : ...................... Date : ........................ Name of Parent/Guardian: .............................................................................. Fold Here Candidate Name: Ansari Faheemuddin Naseeruddin (Signature of the Candidate)

Candidate Signature (Sign within the box only)

(Countersigned by Parent/Guardian) Fold Here

AXIS BANK
( TO BE FILLED IN BY BANK)

JEE COPY

Address: H.No.107 2nd Floor Ashrafiya Manzil Near Rehman Sardar Compound Navi Pada Kalyan Road Bhiwandi Dist Thane Maharashtra PIN Code: 421302 Mobile No: 08237111923 Total Payable in Figures (Including Bank Charges): Rs. 1610.00 Total Payable in Words (Including Bank Charges) Rupees:

Application Form No: C21112282 Date of Birth: 21-11-1990 IIT-JEE 2012 Account No: 911020051391279 Challan No: 33018263 Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)

One Thousand Six Hundred and Ten Only

Date of Deposit: (Signature of the Candidate)

........./.........../ 2011

(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT BOMBAY TO COMPLETE YOUR APPLICATION

Candidate Name: Ansari Faheemuddin Naseeruddin

AXIS BANK
( TO BE FILLED IN BY BANK)

BANK's COPY

Address: H.No.107 2nd Floor Ashrafiya Manzil Near Rehman Sardar Compound Navi Pada Kalyan Road Bhiwandi Dist Thane Maharashtra PIN Code: 421302 Mobile No: 08237111923 Total Payable in Figures (Including Bank Charges): Rs.1610.00 Total Payable in Words (Including Bank Charges) Rupees:

Application Form No: C21112282 Date of Birth: 21-11-1990 IIT-JEE 2012 Account No: 911020051391279 Challan No: 33018263 Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)

One Thousand Six Hundred and Ten Only

Date of Deposit:

........./.........../ 2011
(Authorised Signatory)

(Signature of the Candidate)

JEE COPY

IIT-JEE 2012

INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012

Application Form No.

C21112282

IIT-JEE 2012
Indian Institutes of Technology

BY REGISTERED POST / SPEED POST ONLY

Application Form No.

Choice - I Your Choice of Examination Cities

Choice - II

117

110

APPLICATION FORM NO :

C21112282
To

From Name :
Ansari Faheemuddin Naseeruddin

The Chairman Joint Entrance Examination 2012

Address :

H.No.107 2nd Floor Ashrafiya Manzil Near Rehman Sardar Compound Navi Pada Kalyan Road Bhiwandi Dist Thane Maharashtra

Indian Institute of Technology Bombay Powai, Mumbai PIN Code - 400076

PIN Code : Landline : Email :

421302 08237111923

Mobile :

08237111923

AFAHEEM90@YMAIL.COM

CUT HERE AND PASTE THE UPPER PART ON A5 ENVELOPE

PLEASE INSERT THE APPLICATION FORM IN THE ENVELOPE IN SUCH MANNER THAT THE BARCODE ON THE APPLICATION FORM IS NOT FOLDED. CHECKLIST FOR THE CANDIDATE
1. Tick the box if you have enclosed the following documents:
a. Completed Application Form with your and parent / guardian's signature. b. Your colour photograph (of size 3.5 cm x 4.5 cm) affixed on application appropriately. c. Attested copy of 10th class certifiate for Date of Birth. d. Attested copy of category certificate if you belong to SC/ST/OBC(NCL). e. Request letter for enlarged font question paper if you have poor vision.

2. Retain a photocopy of the completed application form with you. 3. Send your application form to the IIT as mentioned on the address slip.