Application
Content
Auth Code: 48d6ae7bedf21e16ebdc0a811183308d 1. Candidate Name: Ankit Kumar 2. Parent/Guardian Name: Brij Kishor Prasad 3. Date of Birth: 01-01-1994 6. Nationality: Indian 9. First Attempt at JEE: In 2011 12. Enlarged Font Paper Required: No 15. Address: Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand 16. PIN Code: 835223 21. Type of Preparation: Other 23. Board of QE: CBSE 25. Parents' Educational Background: Both Graduates 27. Annual Income of Parent/Guardian: Rs.1,00,000 - 4,50,000 22. Place of 10th Class Schooling: Town 24. Mother Tongue: Hindi 26. Occupation of Parent/Guardian: Business 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: 2009 10. Question Paper Language: English 13. Entitled for DS Seat: No 17. Email ID: [email protected] 18. Mobile No: 09661271281 19. Landline No: 06525225405 20. PIN Code of Permanent Residence: 835223 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: OBC (NCL) 8. Year of Passing QE: Passed on or after 1st Oct 2010 11. Physically Disabled: No 14. Choice of Exam Cities: I. Ranchi (509) II. Rourkela (514)
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: Ankit Kumar (Signature of the Candidate)
Candidate Signature (Sign within the box only)
(Countersigned by Parent/Guardian) Fold Here
STATE BANK OF INDIA
( TO BE FILLED IN BY BANK)
JEE COPY
Address: Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand PIN Code: 835223 Mobile No: 09661271281 Total Payable in Figures (Including Bank Charges): Rs. 1625.00 Total Payable in Words (Including Bank Charges) Rupees:
CBS Screen No: 8888 Fee Type: 000017 Application Form No: C25106889 Date of Birth: 01-01-1994
Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)
One Thousand Six Hundred and Twenty Five Only
Date of Deposit: (Signature of the Candidate)
........./.........../ 2011
(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT KHARAGPUR TO COMPLETE YOUR APPLICATION
Candidate Name: Ankit Kumar
STATE BANK OF INDIA
( TO BE FILLED IN BY BANK) ( CASH CAN BE TENDERED AT ANY SBI BRANCH. )
BANK's COPY
CBS Screen No: 8888 Address: Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand PIN Code: 835223 Mobile No: 09661271281 Total Payable in Figures (Including Bank Charges): Rs.1625.00 Total Payable in Words (Including Bank Charges) Rupees: Tran. No / Journal No: Branch Seal (Within the box only) Branch Code: Fee Type: 000017 Application Form No: C25106889 Date of Birth: 01-01-1994
One Thousand Six Hundred and Twenty Five Only
Date of Deposit:
........./.........../ 2011
(Authorised Signatory)
(Signature of the Candidate)
* Challan can be deposited minimum one day after the generation of challan.
JEE COPY
IIT-JEE 2012
INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012
Application Form No.
C25106889
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
509
514
APPLICATION FORM NO :
C25106889
To
From Name :
Ankit Kumar
The Chairman Joint Entrance Examination 2012
Address :
Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand
Indian Institute of Technology Kharagpur Kharagpur PIN Code - 721302
PIN Code : Landline : Email :
835223 06525225405
Mobile :
09661271281
[email protected]
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.
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: Ankit Kumar (Signature of the Candidate)
Candidate Signature (Sign within the box only)
(Countersigned by Parent/Guardian) Fold Here
STATE BANK OF INDIA
( TO BE FILLED IN BY BANK)
JEE COPY
Address: Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand PIN Code: 835223 Mobile No: 09661271281 Total Payable in Figures (Including Bank Charges): Rs. 1625.00 Total Payable in Words (Including Bank Charges) Rupees:
CBS Screen No: 8888 Fee Type: 000017 Application Form No: C25106889 Date of Birth: 01-01-1994
Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)
One Thousand Six Hundred and Twenty Five Only
Date of Deposit: (Signature of the Candidate)
........./.........../ 2011
(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT KHARAGPUR TO COMPLETE YOUR APPLICATION
Candidate Name: Ankit Kumar
STATE BANK OF INDIA
( TO BE FILLED IN BY BANK) ( CASH CAN BE TENDERED AT ANY SBI BRANCH. )
BANK's COPY
CBS Screen No: 8888 Address: Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand PIN Code: 835223 Mobile No: 09661271281 Total Payable in Figures (Including Bank Charges): Rs.1625.00 Total Payable in Words (Including Bank Charges) Rupees: Tran. No / Journal No: Branch Seal (Within the box only) Branch Code: Fee Type: 000017 Application Form No: C25106889 Date of Birth: 01-01-1994
One Thousand Six Hundred and Twenty Five Only
Date of Deposit:
........./.........../ 2011
(Authorised Signatory)
(Signature of the Candidate)
* Challan can be deposited minimum one day after the generation of challan.
JEE COPY
IIT-JEE 2012
INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012
Application Form No.
C25106889
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
509
514
APPLICATION FORM NO :
C25106889
To
From Name :
Ankit Kumar
The Chairman Joint Entrance Examination 2012
Address :
Ankit Kumar S/O Brij Kishor Prasad, Gulzar Gali, Simdega Dist- Simdega, Jharkhand
Indian Institute of Technology Kharagpur Kharagpur PIN Code - 721302
PIN Code : Landline : Email :
835223 06525225405
Mobile :
09661271281
[email protected]
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.
