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IIT - JEE 2013 QUALIFYING TEST

Brilliant
S T U DY C E N T R E
APPLICATION FORM
Roll Number
Puliyanoor P.O, Mutholy, Pala, Ph: 04822 - 206416, 206516, 206459

Name of the student


(In BLOCK Letters)

Religion MALE FEMALE


Passport
Caste size
colour
Address for photo
Communication

Pin

Phone No. with Code 1.

Mobile No. 2.

Centre Chosen Pala Thodupuzha Changanacherry Ernakulam Kanjirappally


(Please tick the correct column)

Name & Occupation


of the parent with
official Ph. No.

Name of institution last


attended (Class X)
Stream of study Exam Date
(Please tick the correct column) CBSE ISCE STATE OTHERS
MAY 2 MAY 21
For Office use only

Signature of Guardian/Student

N.B:

The application form downloaded from the site is duly filled and send by return of post
with a self addressed envelope affixed with postal stamp of Rs. 10/- in the following
address

IIT JEE 2013 - ADMISSION CELL


BRILLIANT STUDY CENTRE
PULIYANOOR P.O., MUTHOLY
PALA, KOTTAYAM DIST
686573

The envelope should be superscribed “IIT JEE 2013 Coaching programme Admission Test”