Iit-jee Indian Institute Of Technology Application Form 2009
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- Words: 1,728
- Pages: 5
Instruction for Candidate:1. 2. 3. 4. 5.
6. 7.
8.
There are 5 sheets in this file. This sheet (Sheet - 1) to be retained by you carefully. Your Login id is AJAI19022 Remember your password and do not disclose to anyone. Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to IIT KANPUR ZONE a. Stick your color photo in designated place. b. Put your signature at designated place. c. Request your Parent / Guardian to sign at designated place. Sheet - 3 is Application Form to be retained by you for your reference. Sheet - 5 has three copies of bank challan. Take it to bank and pay the fees. Bank will retain a copy with them and will return two copies to you. In those two copies, retain the STUDENT copy with you and attach the IIT copy with application form. Attach attested copies of SSLC certificate where your date of birth is mentioned clearly, and all other applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9. Insert completed Application Form with enclosures (if any) into A4 size cover, without folding. IIT KANPUR ZONE 10. Sheet - 4 contain the address of the to which the application form needs to be posted. 11. Stick the Sheet-4 on top the A4 size cover and post it.
Sheet - 1
IIT COPY
IIT JEE 2010 APPLICATION FORM APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2010 Application No:
A343002262 AJAI KUMAR
1. Name of the Candidate as in the 10th Class Certificate
Zone:
IIT KANPUR ZONE
19. This Attempt at JEE
FIRST
Year of First Attempt
2. Name of the one Parent / Guardian LALLAN BABU as in 10th Class Certificate
20. Type of Preparation
SELF STUDY
21. Counselling
IIT KANPUR COUNSELLING
22. Place of 10th Schooling
CITY
3. Relationship of Person at S.No.2 with the Candidate
FATHER
23. Mother Tongue
Hindi
4. Category
OBC(NCL)
24. Parent's / Guardian's Educational Background
BOTH PARENTS GRADUATE
5. Sub Category
None 25. Parent's / Guardian's Public / Govt Service Occupation 26. Parent's / Guardian's Total Rs.1,00,000 - 3,00,000 Annual Income 27. Fee Amount Rs. 900
Type of Disablity 6. Gender
MALE
7. Nationality
INDIAN
8. Date of Birth (DD/MM/YYYY)
19/02/1993
11. Board of Qualifying Examination
9. Year of passing 10th Class or Equivalent 10. Year of Passing 10+2 Class or Equivalent If Appeared more than once, Year of passing with min Marks
2008
12. Question Paper Language ENGLISH
Appearing in 2010
13. Choice of Examination Center 14. Pincode or Permanent Place of Residence
CBSE
407 - Allahabad 410 - Lucknow 212601
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. I also certify that I have not appreared in JEE in 2008 or earlier and have not accepted admission by paying full fees at any of the IITs, IT-BHU or ISM. 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 JEE 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 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 the Parent / Guardian
LALLAN BABU
Name of the Student
AJAI KUMAR
Signature of the Candidate
Countersigned by Parent / Guardian
15. Address:-
S/O MR. LALLAN BABU(LEKHPAL), BEHIND MISSION HOSPITAL, MAURYA NAGAR ,HARIHARGANJ, FATEHPUR (U.P)
16. Phone / Mobile Number 17. Pincode
09305353923
18. E-Mail Address
[email protected]
Please write your name and application number on the back of photo before affixing
212601
A343002262
Signature(within box) in running hand using black ball point pen only (do not sign in capitals) Send this form along with the necessary documents to IIT KANPUR ZONE
Sheet - 2
STUDENT COPY
IIT JEE 2010 APPLICATION FORM APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2010 Application No:
A343002262
1. Name of the Candidate as in the 10th Class Certificate
AJAI KUMAR
Zone:
IIT KANPUR ZONE
19. This Attempt at JEE
FIRST
Year of First Attempt
2. Name of the one Parent / Guardian LALLAN BABU as in 10th Class Certificate
20. Type of Preparation
SELF STUDY
21. Counselling
IIT KANPUR COUNSELLING
22. Place of 10th Schooling
CITY
3. Relationship of Person at S.No.2 with the Candidate
FATHER
23. Mother Tongue
Hindi
4. Category
OBC(NCL)
24. Parent's / Guardian's Educational Background
BOTH PARENTS GRADUATE
5. Sub Category
None 25. Parent's / Guardian's Public / Govt Service Occupation 26. Parent's / Guardian's Total Rs.1,00,000 - 3,00,000 Annual Income 27. Fee Amount Rs. 900
Type of Disablity 6. Gender
MALE
7. Nationality
INDIAN
8. Date of Birth (DD/MM/YYYY)
19/02/1993
11. Board of Qualifying Examination
9. Year of passing 10th Class or Equivalent 10. Year of Passing 10+2 Class or Equivalent If Appeared more than once, Year of passing with min Marks
2008
12. Question Paper Language ENGLISH
Appearing in 2010
13. Choice of Examination Center 14. Pincode or Permanent Place of Residence
CBSE
407 - Allahabad 410 - Lucknow 212601
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. I also certify that I have not appreared in JEE in 2008 or earlier and have not accepted admission by paying full fees at any of the IITs, IT-BHU or ISM. 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 JEE 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 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 the Parent / Guardian
LALLAN BABU
Name of the Student
AJAI KUMAR
Signature of the Candidate
Countersigned by Parent / Guardian
15. Address:-
S/O MR. LALLAN BABU(LEKHPAL), BEHIND MISSION HOSPITAL, MAURYA NAGAR ,HARIHARGANJ, FATEHPUR (U.P)
16. Phone / Mobile Number 17. Pincode
09305353923
18. E-Mail Address
[email protected]
Please write your name and application number on the back of photo before affixing
212601
A343002262
Signature(within box) in running hand using black ball point pen only (do not sign in capitals) Retain this form for your reference
Sheet - 3
A 3 4 3 0
APPLICATION FORM NO
0 2
2
6
2
BY REGISTERED POST/ SPEED POST
Rs. 900 /-
FOR
JEE - 2010 Indian Institutes of Technology Your Choice of Cities for JEE - 2010
Choice - I
Choice - II
407
410
(See Appendix-III in the Information Brochure) From Name
To The Chairman
AJAI KUMAR
Joint Entrance Examination - 2010
Address
Indian Institute of Technology -
S/O MR. LALLAN BABU(LEKHPAL), BEHIND MISSION HOSPITAL,
THE CHAIRMAN,
MAURYA NAGAR ,HARIHARGANJ,
JEE-2010
FATEHPUR (U.P)
IIT KANPUR
Pin
2
1
2
6
Phone/Mobile:
09305353923
Email (if any) :
[email protected]
0
1
IIT KANPUR ZONE
KANPUR
Pin
2
0
8
0
Sheet - 4
1
6
CASH VOUCHER
BANK'S COPY CASH VOUCHER
)
BRANCH (CODE NO. JEE 2010 – Online Application Fee Payment JEE 2010 FEE COLLECTION A/C NO. 30933155407 [SBI, IIT Madras Branch (Code 1055) ] Name of the Candidate
BRANCH (CODE NO.
S/O MR. LALLAN BABU(LEKHPAL), BEHIND
Present Address
STUDENT’S COPY
)
JEE 2010 – Online Application Fee Payment JEE 2010 FEE COLLECTION A/C NO. 30933155407 [SBI, IIT Madras Branch (Code 1055) ] Name of the Candidate
AJAI KUMAR
Present Address
INSTITUTION’S COPY CASH VOUCHER
BRANCH (CODE NO. JEE 2010 – Online Application Fee Payment JEE 2010 FEE COLLECTION A/C NO. 30933155407 [SBI, IIT Madras Branch (Code 1055) ] Name of the Candidate
AJAI KUMAR
S/O MR. LALLAN BABU(LEKHPAL), BEHIND
AJAI KUMAR
Present Address
S/O MR. LALLAN BABU(LEKHPAL), BEHIND
MISSION HOSPITAL, MAURYA NAGAR
MISSION HOSPITAL, MAURYA NAGAR
MISSION HOSPITAL, MAURYA NAGAR
,HARIHARGANJ, FATEHPUR (U.P) - 212601
,HARIHARGANJ, FATEHPUR (U.P) - 212601
,HARIHARGANJ, FATEHPUR (U.P) - 212601
Date of Birth
19/02/1993
Date of Birth
19/02/1993
Date of Birth
19/02/1993
Mobile / Landline No:
09305353923
Mobile / Landline No:
09305353923
Mobile / Landline No:
09305353923
E Mail ID
[email protected]
E Mail ID
[email protected]
E Mail ID
[email protected]
Category :
OBC(NCL):- Rs.900/-
Category :
OBC(NCL):- Rs.900/-
Category :
OBC(NCL):- Rs.900/-
Head
Credit to
Amount
Application Fees Bank's Charges Total Amount in words :
)
Head
Head
Amount
Credit to
Rs. 900.00
30933155407
Application Fees
Rs.900.00
30933155407
Application Fees
Rs. 900.00
30933155407
Rs. 30.00
98353XXXXXX
Bank's Charges
Rs. 30.00
98353XXXXXX
Bank's Charges
Rs. 30.00
98353XXXXXX
Rs. 930.00 Rupees Nine Hundred And Thirty Only.
Total
Rs. 930.00
Amount in words :
Rupees Nine Hundred And Thirty Only.
A343002262
Amount in words :
Rs. 930.00 Rupees Nine Hundred And Thirty Only. Signature of the Candidate/Remitter
For Receiving Branch use only
For Receiving Branch use only JOURNAL NUMBER
Total
Signature of the Candidate/Remitter
Signature of the Candidate/Remitter
APPLICATION NUMBER
Credit to
Amount
APPLICATION NUMBER
JOURNAL NUMBER
A343002262
For Receiving Branch use only APPLICATION NUMBER
JOURNAL NUMBER
A343002262
1. Please credit Rs.30/- to your Branch Commission A/c No.98353XXXXXX 2. Please note to write the Journal Number in all the challans. 3. Please feed the Application No. in REG/ID/Ref No. Column and Name of the Candidate in the menu while posting.
1. Please credit Rs.30/- to your Branch Commission A/c No.98353XXXXXX 2. Please note to write the Journal Number in all the challans. 3. Please feed the Application No. in REG/ID/Ref No. Column and Name of the Candidate in the menu while posting.
1. Please credit Rs.30/- to your Branch Commission A/c No.98353XXXXXX 2. Please note to write the Journal Number in all the challans. 3. Please feed the Application No. in REG/ID/Ref No. Column and Name of the Candidate in the menu while posting.
SEAL / DATE
SEAL / DATE
SEAL / DATE
AUTHORISED SIGNATORY
AUTHORISED SIGNATORY
AUTHORISED SIGNATORY
6. 7.
8.
There are 5 sheets in this file. This sheet (Sheet - 1) to be retained by you carefully. Your Login id is AJAI19022 Remember your password and do not disclose to anyone. Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to IIT KANPUR ZONE a. Stick your color photo in designated place. b. Put your signature at designated place. c. Request your Parent / Guardian to sign at designated place. Sheet - 3 is Application Form to be retained by you for your reference. Sheet - 5 has three copies of bank challan. Take it to bank and pay the fees. Bank will retain a copy with them and will return two copies to you. In those two copies, retain the STUDENT copy with you and attach the IIT copy with application form. Attach attested copies of SSLC certificate where your date of birth is mentioned clearly, and all other applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9. Insert completed Application Form with enclosures (if any) into A4 size cover, without folding. IIT KANPUR ZONE 10. Sheet - 4 contain the address of the to which the application form needs to be posted. 11. Stick the Sheet-4 on top the A4 size cover and post it.
Sheet - 1
IIT COPY
IIT JEE 2010 APPLICATION FORM APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2010 Application No:
A343002262 AJAI KUMAR
1. Name of the Candidate as in the 10th Class Certificate
Zone:
IIT KANPUR ZONE
19. This Attempt at JEE
FIRST
Year of First Attempt
2. Name of the one Parent / Guardian LALLAN BABU as in 10th Class Certificate
20. Type of Preparation
SELF STUDY
21. Counselling
IIT KANPUR COUNSELLING
22. Place of 10th Schooling
CITY
3. Relationship of Person at S.No.2 with the Candidate
FATHER
23. Mother Tongue
Hindi
4. Category
OBC(NCL)
24. Parent's / Guardian's Educational Background
BOTH PARENTS GRADUATE
5. Sub Category
None 25. Parent's / Guardian's Public / Govt Service Occupation 26. Parent's / Guardian's Total Rs.1,00,000 - 3,00,000 Annual Income 27. Fee Amount Rs. 900
Type of Disablity 6. Gender
MALE
7. Nationality
INDIAN
8. Date of Birth (DD/MM/YYYY)
19/02/1993
11. Board of Qualifying Examination
9. Year of passing 10th Class or Equivalent 10. Year of Passing 10+2 Class or Equivalent If Appeared more than once, Year of passing with min Marks
2008
12. Question Paper Language ENGLISH
Appearing in 2010
13. Choice of Examination Center 14. Pincode or Permanent Place of Residence
CBSE
407 - Allahabad 410 - Lucknow 212601
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. I also certify that I have not appreared in JEE in 2008 or earlier and have not accepted admission by paying full fees at any of the IITs, IT-BHU or ISM. 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 JEE 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 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 the Parent / Guardian
LALLAN BABU
Name of the Student
AJAI KUMAR
Signature of the Candidate
Countersigned by Parent / Guardian
15. Address:-
S/O MR. LALLAN BABU(LEKHPAL), BEHIND MISSION HOSPITAL, MAURYA NAGAR ,HARIHARGANJ, FATEHPUR (U.P)
16. Phone / Mobile Number 17. Pincode
09305353923
18. E-Mail Address
[email protected]
Please write your name and application number on the back of photo before affixing
212601
A343002262
Signature(within box) in running hand using black ball point pen only (do not sign in capitals) Send this form along with the necessary documents to IIT KANPUR ZONE
Sheet - 2
STUDENT COPY
IIT JEE 2010 APPLICATION FORM APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2010 Application No:
A343002262
1. Name of the Candidate as in the 10th Class Certificate
AJAI KUMAR
Zone:
IIT KANPUR ZONE
19. This Attempt at JEE
FIRST
Year of First Attempt
2. Name of the one Parent / Guardian LALLAN BABU as in 10th Class Certificate
20. Type of Preparation
SELF STUDY
21. Counselling
IIT KANPUR COUNSELLING
22. Place of 10th Schooling
CITY
3. Relationship of Person at S.No.2 with the Candidate
FATHER
23. Mother Tongue
Hindi
4. Category
OBC(NCL)
24. Parent's / Guardian's Educational Background
BOTH PARENTS GRADUATE
5. Sub Category
None 25. Parent's / Guardian's Public / Govt Service Occupation 26. Parent's / Guardian's Total Rs.1,00,000 - 3,00,000 Annual Income 27. Fee Amount Rs. 900
Type of Disablity 6. Gender
MALE
7. Nationality
INDIAN
8. Date of Birth (DD/MM/YYYY)
19/02/1993
11. Board of Qualifying Examination
9. Year of passing 10th Class or Equivalent 10. Year of Passing 10+2 Class or Equivalent If Appeared more than once, Year of passing with min Marks
2008
12. Question Paper Language ENGLISH
Appearing in 2010
13. Choice of Examination Center 14. Pincode or Permanent Place of Residence
CBSE
407 - Allahabad 410 - Lucknow 212601
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. I also certify that I have not appreared in JEE in 2008 or earlier and have not accepted admission by paying full fees at any of the IITs, IT-BHU or ISM. 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 JEE 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 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 the Parent / Guardian
LALLAN BABU
Name of the Student
AJAI KUMAR
Signature of the Candidate
Countersigned by Parent / Guardian
15. Address:-
S/O MR. LALLAN BABU(LEKHPAL), BEHIND MISSION HOSPITAL, MAURYA NAGAR ,HARIHARGANJ, FATEHPUR (U.P)
16. Phone / Mobile Number 17. Pincode
09305353923
18. E-Mail Address
[email protected]
Please write your name and application number on the back of photo before affixing
212601
A343002262
Signature(within box) in running hand using black ball point pen only (do not sign in capitals) Retain this form for your reference
Sheet - 3
A 3 4 3 0
APPLICATION FORM NO
0 2
2
6
2
BY REGISTERED POST/ SPEED POST
Rs. 900 /-
FOR
JEE - 2010 Indian Institutes of Technology Your Choice of Cities for JEE - 2010
Choice - I
Choice - II
407
410
(See Appendix-III in the Information Brochure) From Name
To The Chairman
AJAI KUMAR
Joint Entrance Examination - 2010
Address
Indian Institute of Technology -
S/O MR. LALLAN BABU(LEKHPAL), BEHIND MISSION HOSPITAL,
THE CHAIRMAN,
MAURYA NAGAR ,HARIHARGANJ,
JEE-2010
FATEHPUR (U.P)
IIT KANPUR
Pin
2
1
2
6
Phone/Mobile:
09305353923
Email (if any) :
[email protected]
0
1
IIT KANPUR ZONE
KANPUR
Pin
2
0
8
0
Sheet - 4
1
6
CASH VOUCHER
BANK'S COPY CASH VOUCHER
)
BRANCH (CODE NO. JEE 2010 – Online Application Fee Payment JEE 2010 FEE COLLECTION A/C NO. 30933155407 [SBI, IIT Madras Branch (Code 1055) ] Name of the Candidate
BRANCH (CODE NO.
S/O MR. LALLAN BABU(LEKHPAL), BEHIND
Present Address
STUDENT’S COPY
)
JEE 2010 – Online Application Fee Payment JEE 2010 FEE COLLECTION A/C NO. 30933155407 [SBI, IIT Madras Branch (Code 1055) ] Name of the Candidate
AJAI KUMAR
Present Address
INSTITUTION’S COPY CASH VOUCHER
BRANCH (CODE NO. JEE 2010 – Online Application Fee Payment JEE 2010 FEE COLLECTION A/C NO. 30933155407 [SBI, IIT Madras Branch (Code 1055) ] Name of the Candidate
AJAI KUMAR
S/O MR. LALLAN BABU(LEKHPAL), BEHIND
AJAI KUMAR
Present Address
S/O MR. LALLAN BABU(LEKHPAL), BEHIND
MISSION HOSPITAL, MAURYA NAGAR
MISSION HOSPITAL, MAURYA NAGAR
MISSION HOSPITAL, MAURYA NAGAR
,HARIHARGANJ, FATEHPUR (U.P) - 212601
,HARIHARGANJ, FATEHPUR (U.P) - 212601
,HARIHARGANJ, FATEHPUR (U.P) - 212601
Date of Birth
19/02/1993
Date of Birth
19/02/1993
Date of Birth
19/02/1993
Mobile / Landline No:
09305353923
Mobile / Landline No:
09305353923
Mobile / Landline No:
09305353923
E Mail ID
[email protected]
E Mail ID
[email protected]
E Mail ID
[email protected]
Category :
OBC(NCL):- Rs.900/-
Category :
OBC(NCL):- Rs.900/-
Category :
OBC(NCL):- Rs.900/-
Head
Credit to
Amount
Application Fees Bank's Charges Total Amount in words :
)
Head
Head
Amount
Credit to
Rs. 900.00
30933155407
Application Fees
Rs.900.00
30933155407
Application Fees
Rs. 900.00
30933155407
Rs. 30.00
98353XXXXXX
Bank's Charges
Rs. 30.00
98353XXXXXX
Bank's Charges
Rs. 30.00
98353XXXXXX
Rs. 930.00 Rupees Nine Hundred And Thirty Only.
Total
Rs. 930.00
Amount in words :
Rupees Nine Hundred And Thirty Only.
A343002262
Amount in words :
Rs. 930.00 Rupees Nine Hundred And Thirty Only. Signature of the Candidate/Remitter
For Receiving Branch use only
For Receiving Branch use only JOURNAL NUMBER
Total
Signature of the Candidate/Remitter
Signature of the Candidate/Remitter
APPLICATION NUMBER
Credit to
Amount
APPLICATION NUMBER
JOURNAL NUMBER
A343002262
For Receiving Branch use only APPLICATION NUMBER
JOURNAL NUMBER
A343002262
1. Please credit Rs.30/- to your Branch Commission A/c No.98353XXXXXX 2. Please note to write the Journal Number in all the challans. 3. Please feed the Application No. in REG/ID/Ref No. Column and Name of the Candidate in the menu while posting.
1. Please credit Rs.30/- to your Branch Commission A/c No.98353XXXXXX 2. Please note to write the Journal Number in all the challans. 3. Please feed the Application No. in REG/ID/Ref No. Column and Name of the Candidate in the menu while posting.
1. Please credit Rs.30/- to your Branch Commission A/c No.98353XXXXXX 2. Please note to write the Journal Number in all the challans. 3. Please feed the Application No. in REG/ID/Ref No. Column and Name of the Candidate in the menu while posting.
SEAL / DATE
SEAL / DATE
SEAL / DATE
AUTHORISED SIGNATORY
AUTHORISED SIGNATORY
AUTHORISED SIGNATORY
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