Professional Documents
Culture Documents
1. Student's Name
2. Mother's Name
3. Father's Name
4. Father's Occupation
5. Add At Po. Ps.
Dist. State Pin Code
6. DOB D M Year
7. Sex M F
8. Mob. ,
9. School Name
ACADEM I C PERFORM AN CE
Cl a s s Year Board M a t h s / B i o % / Gr a d e A g g r % / Gr a d e
Pl a c e & Da t e
Signature of Student
SL.NO. Date..................
Name :
Father's Name : Authorised by
samarpan academy De t e rm ine d t o Com pe t e
For : JEE (ADVANCE + MAINS) / NEET / OLYMPIADS / KVPY / NTSE
(A T e a m of N I T Wa ra nga l)
South of Indira Gandhi Stadium, Housing colony, Purnea - 854301
e m a il : sa m a rpa na c a de m y2 0 1 9 @gm a il.c om w e bsit e : sa m a rpa na c a de m y.in
M ob.: 7 0 6 1 5 6 1 2 6 6 , 9 4 7 1 6 2 8 6 7 2
ADM I SSI ON FORM
Form N o. Roll N o.Assigne d.
Pe rsona l De t a ils
N AM E
Da t e of Birt h Ca t e gory
Pa s s p o r t s i ze
D D MM Y Y Y Y Ge n OBC SC/ST PH Ph o t o
Ge nde r Re gion M ot he r o
T ngue
M a le Fe m a le Rura l U rba n
M obile N um be r St ude nts÷ Em a il :
Fa t he ÷
rs/Gua rdia n÷
s Name Oc c upa t ion
Gua rdia n÷
s Phone N um be r Gua rdia n÷
s Em a il :
0CODE
Corre sponde ncAddre
e ss Pe rm a ne ntAddre ss
Pin Pin
VIII
EDU CAT I ON A L
DETA I L S
IX
XI P C M B
XII P C M B
T ERM S & CON DI T I ON S
1. Inc om pletform e w illbe rejec t ed.It is c om pulsoryt o 9. Any st udy m at erialgiven during t he c lasses or 18. The st udentw ho is enrolledw it hSam arpan Ac adem y
at t ac h phot oc opy of m ark sheet of c lass X / XII and ot herw ise, w illnot be givent o t hosest udent s, w hoare Purneaw illhavet o w orkhardregularly . In c ase,if t he
rec entpassportsize phot ographs w it ht he adm ission absentw it houtpriorapplic at ion from t he parent s.No t eac hersfeel t hat t he st udentis not w ork inghard,
form . The Inst it ut ereservest he right t o use t he request / personal appoint m ent s in t his regard shallc reat be ingindisc iplineor using unfairm eans in t he
phot ographfor public it in y c ase t he st udentsec ures ent ert ained. Missedappoint m entinst hisregardshallbe Inst it ut eor prem ises,irregularin at t endanc e,not
posit ion/suc c ess in Ent ranc eEx am s. ent ert ained. MissedClassesandm at erials w illbe given responding properly , he/shem aybe ex pelledfromt he
onlyaft erfullpaym ent . Inst it ut The
e. dec ision of t heManagingDirec t orin t his
(a) A student after qualifying Admission cum 10. (a) If t he st udy m at erialprovidedt o t he st udentis regardw illbe fl naland bindingon t hest udent /parent .
sc holarship Testandt ak ingadm issionat Sam arpan No feeor partof t hefeew illbe refundedin suc hc ases.
lost /m isplac ed, a duplic atset e of t hebook (s)c anbe
Ac adem y,Purneaw illbe boundby t herules and obt ainedfromt he Inst it utagainst e t he paym entof 19. Any st udentc aughtem ployingunfairprac t ic during e
regulat ions of inst it ut eand in all m at t ers Rs 300perbook . t he Adm issionc um Sc holarshipTest is liable for
w hat soever t he responsibilitwyillbe of inst it ut e im m ediatrem e ovalfromt heex am inat ion hall,and no
only. (b) If t hebagprovidedt ot hest udentis lost /m isplac ed, a refundof Adm issionc um Sc holarshipTest fee paid
new bag c an be obt ained from t he inst it ut e against shallbe m ade.
(b) It is for t hest udenthim self/herself t o see w het her t hepaym entof Rs.500.
he/sheis eligiblefora part ic ular ex am inat ion or not . 11. If a st udentis absentor m issesa t est he/she 20. The parent sc an m eett he Cent re-In-c harge for any
, c anc ollec t enquiry about t heir w ard÷ s progress or any ot her
The Inst it ut does
e not hold it selfresponsibleif a his/herquest ionpaperfrom t he offl c e w it hin10 days
st udents ÷adm ission formc annotbe forw arded or is problem concerning their ward with the prior
fromt hedat eof t het est failing , w hic ht hequest ionpaper appoint m ent only.
rejec t edby t he ex am iningbody on any ground w illnotbe givent ohim /her.
w hat soever . Suc ha st udentc annotc laima refund 21. In c aseif any parent /guardian m isbehavesw it hany
of t hew holeor anypartof t hefeehe/shehaspaidt o 12. If any st udentdoesnot pay t hefee on t hedue dat eas st aff m em berof t he Inst it ut e,his/herw ard c an be
t heInst it ut e. m ent ionedin t he rec eiptor is default erin t he fee rust ic at edfromt heInst it utand e no c laimof refundof
paym enthe/she , shallbe st oppedfrom at t endingt he suc hst udentw illbe ent ert ained. The dec isionof t he
3. St udent enrolled
s w it hSam arpan Ac adem y, Purnea w illc lasses.It is t herefore, in t he int erestof t he parent s& Direc t orw illbe fl naland bindingon t he st udentand
have t o provide phot oc opyof Adm itCard of various st udent st hatt heyshoulddepositt he fee on t he due parent /guardian.
Ent ranc eEx am s.,as soonas t heyrec eivet heiradm it dat esm ent ioned in t herec eipt .
c ards from t he ex am iningbody before/duringTest 13. If t het uit ionfee is not paidin lum psum ,subm ission 22. If anyt ypeof m ishapoc c ursin t heprem isesof Sam arpan
of Ac ademPurneay, bec auseof sit uat ions beyondc ont rol
Seriest o be c onduc t edfailingw hic ht he st udent postdat edc hequesis m andat ory . In c ase,postdat ed
shallnotbe allow edt o at t endfreeTestSeries& or any nat ural c alam it yof any t ype suc h as
c hequesare not subm it t ed or get bounc edt hena lat e eart hquak e, ‡oods,fl re,elec t ricshortc irc uitet c ,t he
w illnotbe givenTestpapers. fee of Rs 50/- per day shall be c hargedon t he inst it ut eshall not be responsiblein any m anner
inst allm ent due.How ever , inst allm ent w illbe ac c ept ed w hat soever .
4. Sam arpan Ac adem y, Purnea reservesit s rightt o m ak e w it hlat efeeonlyupt o3w eek sfromduedat eaft erw hic h
any alt erat ion in it s program s/ venue/ t im inganddays t henam eof st udentw illbe st uc koff. 23. Aft er deposit ingm oney t ow ards’Regist rat ion&
of c lassesw it houtany prior not ic et o anybody . Adm ission÷, if a st udentbec om esdisint erest ed in t he
The dec isionof t heDirec t orw illbe fl naland binding 14. Onc e t he nam eof a st udentis st ruc k -of f due t o non- Inst it utdue
e t o any reasonw hat soever and w ant st o
on t he st udent&s t heparent s. paym entof feeform oret han3 w eek sfromt heduedat e, t ak eany. The regist rat ion / adm issionfee deposit ed
t hest udentshallhavet opayRs 500forre-adm ission. t ow ardsa part ic ular
c ourse w illnotbe adjust edagainst
5. It is c om pulsory/m andat tory o providee-m ail I.D. /
MobileNo.of t hest udent/ fat her/ guardian.Theresult 15. If at anypointof t im e,t heCent ralGovt .furt herinc reases anyot herc ourse.
of t est sor any ot herinform at ion of t he inst it utwe illbe servic et ax ,(ex ist ing rat eof servic et axis 18%)t heex t ra his/herm oneybac k ,t he Inst it ut we illnot refundt he
sent t o t he st udent by SMS and on his / her e-m ail am I.D.ountof servic et axw illbe borneby t hest udentfrom s m oneydeposit ed t ow ardsRegist rat ion fee/ Adm ission
e not be responsiblefor any inform at ion t hedat eof enforc em ent
Inst it ut shall of t heac tby t heGovt . fee.How ever , if a st udentappliesforrefundbeforet he
regarding result or anyt hing else is not rec eived 16.byA stt he
udentis notallow edt o c arrym obilephone/ I-padin c om m enc em ent of c ourse/ c lasses,only adm ission
st udentif he/shehasnotgivenhis/here-m ailI.D./ SMS t hec lasses.In c ase,if he/shec arriesm obilephonein fee and 10% of t uit ionfee w illbe refundedalongw it h
in t heAdm ission Testformat t het im eof adm ission. t hec lasses,t henit shouldbe sw it c hed off. TheInst it ut e PDCs subm it t ed, if any. The regist rat ion / adm ission
is not responsible for any loss / t heft of m obile phone in fee deposit edt ow ardsa part ic ular c oursew illnot be
6. Any c hangeof address,m obileno & e-m ailaddress
t heInst it ut e. adjust edagainstanyot herc ourse.
shouldbe not ifl edin w rit ingt ot heoffl c ew it hin10 days.
7. Eac hst udentw illbe issuedan ident itcyard.Theent ryin 17. If anyst udentabsent shim self/herself form oret han10
t hec lasses/Inst it w utill
ebe onlyw it hIdent itCard,
y if t he days c ont inuously w it hout any prior w rit t enapplic at ion,
Ident itcyardof a st udentis lost /m isplac ed, a duplic atI-e he/shew illnotbe allow edt oat t end/ joint hec lassesand
c ardc anbe ask edfromt heInst it utagainst e paym entof w ill not be given any t est paper(s),he/she m ay be
Rs 100. If any st udentis foundm isusingt he I-c ard, deem edt o be ex pelledfromt heInst it ut e. No separat e
he/shew illbe rust ic at ed fromt heInst it ut e. int im at ion
w ill
be sent t o t he parent s.
No fee or partof t he
fee paid/enc ashed w ill be refunded in sucThe h c ases.
8. A st udentw hois lat eby 10 m inut esforc lasses/t estws,ill dec ision of t he Managing Direc t or in t his regard w ill be
notbe allow edt oent ert hec lassroom . fl nalandbindingon t hest udent&s parent s.
Che c kList :
1 . I t i s c o m p u l s o rt yoa t t a c h eadp h o t o c o poyf m a r ks h e e to f t h el a s tb o a r do r a n ye q u i v a l e nEx
t am .
2 . I t i s c o m p u l s o rt yoa t t a c ht h r e ee x t r ar e c e npt a s s p o rsti zep h o t o g r a p hasl o n gw i t ht h ef o r m .
I h a v er e a dt h et e r m s& c o n d i t i o nosfSa m a r p a n A c a d e m y , Pu ranneda p r o m i s e t oa b i d eb y t h es a m e .
M ob.: 7 0 6 1 5 6 1 2 6 6 , 9 4 7 1 6 2 8 6 7 2
e m a il.: sa m a rpa na c a de m y2 0 1 9 @gm a il.c om w e bsit e : sa m a rpa na c a de m y.
samarpan academy Determined to Compete
samarpan aca Deter
A Premier Institute for JEE (Advance + Mains) & NEET A Premier Institute for JEE (Advance
(A T e a m of N I T Wa ra nga l) (A T e a m of N I T W
South of Indira Gandhi Stadium, Housing colony, Purnea - 854301 South of Indira Gandhi Stadium, Housing colon
Samarpan Academy, Purnea is an exclusive centre for quality Samarpan Academy, Purnea is an exclusive c
teaching in JEE (Advance+Mains) & NEET. It is a preface teaching in JEE (Advance+Mains) & NEET
learning centre with a dedicated team of experienced faculties learning centre with a dedicated team of expe
handpicked for their indepth knowledge and mastery of the handpicked for their indepth knowledge and
various facets of the subjects. various facets of the subjects.
Registration is going on.... Registration is goin
Cha ndra ha s K um a r J im i Ana nd Ra je sh Ana nd Shya m na nda n K um a r Cha ndra ha s K um a r J im i Ana nd Ra je sh Ana nd S
M a t h s ( E x . F a c u lt y N a r aP yhayns aic) s ( E x . F a c u lt y C a r e e r CP ho einmt )is t r y ( E x . F a c u lt y F I I T J E E ) M a na ging Dire c t or M a t h s ( E x . F a c u lt y N a r aP yhayns aic) s ( E x . F a c u lt y C a r e e r CP ho einmt )is t r y ( E x . F a c u lt y F I I T J E E )
(B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l) (B. T e c h, GGSI PU De lhi) (B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l)
M ob.: 7 0 6 1 5 6 1 2 6 6 , 9 4 7 1 6 2 8 6 7 2 M ob.: 7 0 6 1 5 6 1 2 6 6 , 9
e m a il.: sa m a rpa na c a de m y2 0 1 9 @gm a il.c om w e bsit e : sa m a rpa na c a de m y.in
e m a il.: sa m a rpa na c a de m y2 0 1 9 @gm a il.c om w e b
samarpan academ De t e rm ine d t o C
Admission is
Open Cha ndra ha s K um a r J im i Ana nd
M a t h s ( E x . F a c u lt y N a r a y aPnhay) s ic s ( E x . F a c u lt y C a r e e r P oCin
(B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l)
Ra je sh Ana nd
h et )m is t r y ( E x . F a c u lt y F I I T J E E )
(B. T e c h, N I T Wa ra nga l)
mission is
Open Cha ndra ha s K um a r
M a t h s (E x . F a c u lt y N a ra y a n a )
(B. T e c h, N I T Wa ra nga l)
J im i Ana nd
P h y s ic s (E x . F a c u lt y C a re e r P o in t )
(B. T e c h, N I T Wa ra nga l)
st ra t ion for Re gist ra t ion for Chandrahas Kumar Jimi Anand Rajesh A
M a t h s (E x . F a c u lt y N a r a y aPnhay) s ic s (E x . F a c u lt y C a r e e r P oCinh et )m is t r y (E x . F a
(B. Tech, NIT Warangal) (B. Tech, NIT Warangal) (B. Tech, NIT
10th & 12th 9 t h, 1 0 t h & 1 2 t h
oing on.... is going on....
FREE DEMO CLASSE
Cha ndra ha s K um a r J im i Ana nd Ra je sh Ana nd
M a t h s ( E x . F a c u lt y N a r a y aPnhay) s ic s ( E x . F a c u lt y C a r e e r P oCin
h et )m is t r y ( E x . F a c u lt y F I I T J E E )
(B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l) (B. T e c h, N I T Wa ra nga l)
ndira Gandhi Stadium, Housing colony, Purnea - 854301South of Indira Gandhi Stadium, Housing colony, Purnea -
61561266, 9471628672email.: samarpanacademy2019@gmail.com web. : samarpanacademy.in Mob.: 7061561266, 9471628672email.: samarpanacademy2019@gmail.com web. : samarpa
samarpan academy De t e rm ine d t o Com pe t e
A Premier Institute for IIT - JEE (Advance + Main)/
NEET / FOUNDATION (IX & X) / BOARDS
(A T e a m of N I T Wa ra nga l)
S For : S
A A
M IIT - JEE M
A (ADVANCE + MAIN) A
R R
P NEET P
A A
N FOUNDATION N
(IX&X)
A A
C OLYMPIADS C
A A
D KVPY D
E E
M NTSE M
Y Y
samarpan
ACADEMY
Determined to Compete...