Academic Session: 2013-2014

For Yearlong Classroom Contact Programmes (YCCPs) for Pre-Engineering & Pre-Medical Examinations

APPLICATION FORM

No. 1. Application Form No.

IMPORTANT INSTRUCTIONS: n Please go through the ResoGuide (Information Booklet) & Information Brochure very carefully before filling up the application form. Do take the help of How to fill Application Form mentioned in ResoGuide to fill the Application Form. n Use only Black/ Blue Ball Point/ Gel Pen to complete the Application Form. n Use only CAPITAL LETTERS of English Language to complete the Application Form. n Tick ( ) in the appropriate box wherever double box like this is given.
3. Name of the Applicant: (Leave a box blank between first, middle & last Name) 4. Father's Name: (Leave a box blank between first, middle & last Name) 5. Mother's Name: (Leave a box blank between first, middle & last Name) 6. State of Domicile:

2. Paste your recently taken passport size Colour Photograph (3.5cm X 4.5 cm) by applying gum only. Do not Staple the photo.

10. Choice of Study Centre

Study Centre Campus

11. Religion
Hinduism Islam Parsism Sikhism Christianity Buddhism Any Other

7. Date of Birth:

8. Gender:

9. Category:
Jainism

12. Course you are applying for Yearlong Classroom Contact Programmes (YCCPs) :

Target: JEE (Main+Advanced) | For IITs

S.No.
1.

Target: JEE (Main) | For NITs

S.No. Target
JEE (Main) 2015 JEE (Main) 2015 JEE (Main) 2014 JEE (Main) 2014 JEE (Main) 2014 JEE (Main) 2014

Target: NEET (AIPMT)/AIIMS

S.No. Target
NEET 2017 NEET 2016 NEET 2015 NEET 2015 NEET 2014 NEET 2014 NEET 2014 NEET 2014

Target
JEE (Main+Adv) 2017

Class Course Name

IX X XI XI XII XII XIII XIII WISDOM WINNER VIKAAS VIPUL VIJETA VISHWAAS VISHESH VIJAY JN JT JA JB JP JF JD JR

Class Course Name

XI XI XII XII XIII XIII ABHINAV AADHAAR ANOOP AKHIL ABHYAAS AJAY EA EB EP EF ED ER

Class Course Name

IX X XI XI XII XII XIII XIII WISDOM WINNER SAKSHAM SAMARTH SANKALP SAMBHAV SAMPOORN SAFAL MN MT MA MB MP MF MD MR

1. 2. 3. 4. 5. 6.

1. 2. 3. 4. 5. 6. 7. 8.

2. JEE (Main+Adv) 2016 3. JEE (Main+Adv) 2015 4. JEE (Main+Adv) 2015 5. JEE (Main+Adv) 2014 6. JEE (Main+Adv) 2014 7. JEE (Main+Adv) 2014 8. JEE (Main+Adv) 2014

13. Medium of studies to be opted in Resonance:

(Hindi Option is available only at Kota & selected Study Centres)

14. Choice of Test Date & Test Centre for ResoNET* - 2013 or ResoMOST#-2013
# [*For JEE (Main+Adv.) Courses only] (Direct Admission for JEE (Main) & NEET (AIPMT) Courses) [ Scholarship Test for NEET Courses only)

English

Hindi

Test Centre

15. Parents Permanent Residence Address (Do not write your or Fathers Name here):
House No./Street: Area/Colony/Village: City/Town/P.O.: Tehsil/Taluka: District : State : PIN Code : Mobile No. (Self): 0 Mobile No. (Parents): 0 Telephone No. (Landline) : 0
(STD Code) (Telephone No.)

Country :

E-mail ID (Self): E-mail ID (Parents):

16. Emergency Mobile No./E-mail (other than parents) :

Relationship: Mobile No.: 0

17. Alternative Mobile No./E-mail (other than parents) :

Relationship: Mobile No.: 0

e-mail:

e-mail:

18. Have your real brother(s)/sister(s) ever studied in RESONANCE?

S.No. 1. 2. Name

Yes

No

If Yes, provide the details in the table below:

Relationship (Brother/Sister) Class Course Name Final Batch Examination Qualified IIT-JEE IIT-JEE AIPMT AIPMT AIEEE AIEEE

Last Resonance Roll No. Academic Session

19. Past Performance in Competitive/Talent Examinations (fill the details, only if relevant):
S. No. 1. 2. 3. 4. 5. 6. 7. Competitive/Talent Examination NTSE Olympiads** (P/C/M/B/A/Jr. Sc.) KVPY IIT-JEE / JEE (Main+Advanced) AIPMT / NEET AIEEE / JEE (Main) Other: (____________________) Year (Qualified) Level Qualified (I/II/Final) Max. Marks Marks Obtained % Marks All India Rank (AIR) All State Rank (ASR) Remark (s) (if any)

**Olympiads conducted by HBCSE only.

20. Parents'/Guardian's Occupation:

S.No. 1. 2. 3. Occupation Agriculture Artist Business/Self-employed S.No. 4. 5. 6. Occupation Defence Services Doctor Engineer S.No. 7. 8. 9. Occupation Law Practice Public/Govt. Service Private Service S.No. 10. 11. 12. Occupation Teaching/Research Unemployed Other

21. Past Three Years' Academic Performance (including current year) in School/Board Examinations:
Class VII VIII IX X XI XII Address & Phone No. of Class - X School Address & Phone No. of Class - XII School
0 (STD Code) 0 (STD Code) (Telephone No.) (Telephone No.)

Year of Passing Out

Name of the School

City/Town/Village

District

State

Board

% Marks/Grade % Marks/Grade in (Aggregate) (Sc+M) (PCM/B)

22. How did you come to know about Resonance? (In the Source Details, write Newspaper/Magazine/Website's Name, Friend/Relative/Old Student's Name, address & Contact No.)
S.No. 1. 2. 3. 4. Source Old Resonance Students Friends/Relatives Newspaper Resonance Website S.No. 5. 6. 7. 8. Source STaRT 2012 / 2013 Seminar in School/City Other Talent Search Exam Internet/E-mail S.No. 9. 10. 11. 12. Source FM Radio Outdoor/Hoardings Television Canopy/Leaflet S.No. 13. 14. 15. 16. Source Education/Fair Book Magazines Mobile/SMS Any Other Write below the details of source that you have ticked

23. Parents'/Guardian's Bank Account Detail: (any Excess Fee/Refund/Reward/Caution Money amount entitled by the enrolled student shall be deposited by Resonance in this account only)
Account Holder's Name: Account No.: Bank Name: City: Relationship: Branch Name:

Would you like to stay in a HOSTEL managed by Resonance (Applicable to those who are interested to study only at Kota) : Yes

No

May think later

DECLARATION
I/We, the undersigned, hereby solemnly and truly declare and affirm that, the information provided by me/us in the application form (as well as the copies of examination forms, qualification documents, etc. as also cheques, demand drafts submitted to the institute, towards payment of course fee) is true and correct. Further, I/We have understood and agree that any misrepresentation or concealment of facts, will justify the denial/ cancellation of undersigned student's admission, or expulsion from the institute at any stage of the Academic Session. I/We acknowledge having read the Terms and Conditions of the application form and ResoGuide & Information Brochure, a copy of which has been duly received by me/us and which forms an Integral part of Admission Packet for admission in the institute for the Academic Session 2013-14, and hereby, irrevocably agree to abide by the same. Further, if the undersigned student is admitted to the institute for the study course applied by him/her, I/We promise to abide by all the rules & regulations and disciplinary norms of the institute as long as undersigned student remains a registered student of RESONANCE. I/We, hereby also declare that while being an enrolled student of Resonance, the undersigned student will be responsible for providing relevant details of all the competitive examinations (in the form of true copies of the application form of the relevant examination) which he/she will be appearing in the future by virtue of coaching & academic support from the institute. Further, I/We, hereby give our free consent to the institute for using the result, photograph & testimonials of the undersigned student, in any form, for its growth strategies and developmental plans, if the undersigned student, succeeds in any of the competitive examinations through coaching and academic support from Resonance at any point of time during the Academic Session 2013-14, and will never have any objection for it.

Signature of one of the Parents/ Guardian : _________________________________ Date: __________________________ If Signed by Guardian,: write his/her Name
Note: In case of any legal disputes, the jurisdiction of court of Kota (Rajasthan) shall be applicable.

Signature of the Student: _________________________________________ Date: ______________________ Relationship: Place: __________________________

Place: ____________________________

Contact No.:

CORPORATE OFFICE: Resonance Eduventures Pvt. Ltd., CG Tower, A-46 & 52, IPIA, Near City Mall, Jhalawar Road, Kota (Raj.)-324005 Reg. Office: J-2, Jawahar Nagar Main Road, Kota (Raj.) - 324005 | Tel. No. : 0744-3012222, 3022222, 3192222 | Fax : 022-39167222, 0744-2427144 Toll Free: 1800-200-2244 | e-mail: contact@resonance.ac.in | Website: www.resonance.ac.in