JEE- 2011

APPLICATION FORM FOR ADMISSION INDIAN INSTITUTES OF TECHNOLOGY Bhubaneswar, Bombay, Delhi, Gandhinagar, Guwahati, Hyderabad, Indore, Kanpur, Kharagpur, Madras, Mandi, Patna, Rajasthan, Roorkee, Ropar ISM Dhanbad and IT-BHU Varanasi 1. JEE-2011 Registration No. 2. a) All India Rank b) Category Rank 3. JEE-2011 Application No. 4. Nationality (I-Indian/F-Foreigner)
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5. Category
[Please wherever applicable] GE OBC(NCL) SC ST DS PD

6. Applicants Name 7. Date of birth (DD/MM/YYYY):.... 8. Sex:.

9. Parents/Guardians Name. 10. Permanent Address Pin Code... Mobile No.. 12. Academic Qualifications Examination 10 Class 10+2 Class/ Intermediate Any other public examination 13. Are you colour blind or uniocular? Yes/No
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11. Address for Communication . . ... Pin .

Code.

Email id

School/College

Board/University

Year of Passing

Percentage of marks

14. Declaration: I hereby declare that the particulars stated above are true to the best of my knowledge and belief. In the event of suppression or distortion of any fact, I understand that my admission/degree acquired is liable to cancellation. I also understand that the decision of the Joint Admission Board regarding my admission to any of the IITs/ ISM Dhanbad/ IT-BHU Varanasi is final and I shall abide by the rules and norms of the discipline of the Institute which I join. Left thumb impression of the Candidate.. Place:. Date:... Countersigned by Parent/Guardian Signature of the Candidate

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