Form No:

An IIT Kharagpur Alumni Initiative

Student Name:

Personal Details

Date of Birth:
Contact No 1:

DD/MM/YYYY

Sex:

Student/Parent

Female

Male

Parent/Guardian

Contact No 2:

Residential/Correspondence Address:
City:

Pin Code:

Fathers Name:

Occupation:

Mothers Name:

Occupation:

Name & School/College of Sibling(s) (If applicable):

Academic Details

School:
Board: ICSE

School of the Student

ISC

Class In 2015-16 session

WBBSE

WBHS

CBSE

Aggregate Marks obtained in last exam (School/Boards) %

Others

Rank (if applicable) _________________

Exams Appeared in: Name:__________________________ Year_______ Marks/Rank ___________________

like NTSE,
Olympiads,
KVPY, NSEJS
Mode of Study:

Name:__________________________ Year_______ Marks/Rank ___________________

Name:__________________________ Year_______ Marks/Rank ___________________
Self Study

Coaching/Tutor

E-Learning

Correspondence (Choose 1 or more)

How did you come to know about Edudigm?

Newspaper Ad

School

Online/SMS

Others

Please specify

Have you attend any of the events organized by Edudigm or Eduscience? If yes, then mention the following:
Event/Workshop Name:

Venue:

Date:_________

Program Interested: Classroom

Correspondence

e-Learning

Test Series

Course Interested: Engineering(11&12)

Medical11&12)

Foundation(9&10

School+ (7-10)

Any queries you like to ask our experts, Please mention:

Would you like to appear for the Admission Test?

Test Date:

Yes

No

Center:

Student Name:
Class:

Exam Center:
Authorized Signatory

Exam Date:

Office Use

Tell us more

Friends/Relatives

Recent Colour
Passport Size Photo