Application Form For DLP Academic Session 2012-13

VIBRANT ACADEMY
(India) Pvt. Ltd.
All Entries must be filled in capital letters only

Form No.
Test Centre 1st Preference Test Centre 2st Preference

Course Applied for

For office use only

Vibrant All India Test Series

(VAITS) At Centre

Vibrant Roll No.

Vibrant Full Syllabus Test Series (VFTS) At Centre Vibrant JEE Success Package Vibrant All India Test Series Vibrant All India Open Test PERSONAL INFORMATION Name: Fathers Name: Mothers Name: Date of Birth: D D / M M / Y Y Y Y Gender: Business (Nature of Business) Service (Name of Company Department with Post) Mobile Number Student PAST ACADEMIC PERFORMANCE
Examination 10th Class Board
(CBSE/ICSE/Other (specify)

(VJSP) (VAITS) Postal (VAIOT) At Centre

Paste latest Passport Size Colour Photograph

Vibrant Full Syllabus Test Series (VFTS) Postal

Male

Female

Category: Gen
(Tick appropriate box)

SC

ST

PD

OBC

Fathers/ Guardians

Father/Guardian
Year of Passing Max. Marks Max. Obtained %age Marks %age Marks Sc.Maths/PCM

Subject Science Maths Physics Chemistry

12th Class

Maths

FEE CATEGORY (If Applicable)

Tick appropriate box Category
A B C D E F G H

Students must submit attested copy of relevant document as proof.

ACADEMIC ACHIEVEMENTS

Are you NTSE qualified Yes IIT-JEE Other Other Merit Position( Academic Awards Year Year Year )in Year

No

If yes, upto which level: Yes No If yes then Rank

Qualified in Main List Rank Rank Position

Exam Name Exam Name Board

COURSE FEE DETAILS

(Application form received without demand draft of fee will be rejected without intimation)

Amount
CONTACT DETAILS

DD Number

Date

Drawn on Bank (Name)

Correspondence Address (In Capital)

Permanent Address (In Capital)

City State Residence STD Code Office STD Code Mobile e-mail address Pin Tel Tel State Residence STD Code Office STD Code Mobile e-mail address

City Pin Tel Tel

RULES & REGULATION

l l l l l l l l l l l l l

Mention your correct name and address while filling the Application Form. Please keep visiting our website at regular interval to keep yourself update with current happenings and changes. Incase you don't receive the admit card you can download the same from our website 4 days prior the test date. If the student indulges in any kind of unfair or unsocial activity, He/She will be responsible for any consequences. Medium of Test paper and instruction will be in English only. Students falling in category (A-H) of fee details table mentioned in DLP leaflet must submit attested copies of relevant document as proof. Signature of student and father/guardian on application form is must otherwise form will be rejected. We reserve the right to cancel or change Test centre and Test schedule. Please check list of Test centre and confirm from Head Office before submitting application form. Fee once deposited will not be refunded under any circumstances. All disputes are subjected to Kota city (Rajasthan) jurisdiction only. If there is any change in rate of Service Tax/any other Tax during the course period the same will be applicable & student will bear it. You must submit copy of JEE application form in time, the last date of which will be intimated to you separately. The institute reserve the right to disallow you to appear in Test in such case.

DECLARATION 1. I declare that I have read the Rules and Regulations of the institute as mentioned and understood the contents fully and agree to abide by them. 2. I am seeking admission in my interest. 3. I shall inform & provide my roll no. of various competitive examination as soon as I received Admit Card of these exams. 4. If I succeed in any of the competitive examination, the institute will have all the rights to using my result & photograph and I will never ever have any objection or protest against this. 5. I will not claim the fees once deposited.

Signature (Applicant) with date

Signature (Father/Guardian) with date