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Instructions for Candidate:

1.
There are 5 sheets in this file.
2.
This sheet (Sheet - 1) is to be retained by you carefully.
3.
Your Login id is PRAN28081
4.
Remember your password and do not disclose it to anyone.
5.
Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to
IIT BOMBAY ZONE
a.
Stick your color photo at the designated place.
b.
Put your signature at the two designated places.
c.
Get the signature of your Parent / Guardian at the designated place.
6.
Sheet - 3 is the Application Form and should be retained by you for your referen
ce.
7.
You have selected NEFT mode for payment. The details for the fund transfer are i
n Sheet 5 of this form.At the end
of fund transfer, note down the Unique Transaction ID/ Reference no. (UTR) in th
e top left corner of the Application
form (Sheet 2).
8.
Attach attested copies of Tenth Class/SSLC certificate where your date of birth
is mentioned clearly, and all other
applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9.
Insert completed Application Form with enclosures (if any) into an A4 size envel
ope. DO NOT FOLD THE
APPLICATION.
10.
Sheet - 4 contains the address of the IIT BOMBAY ZONE
to which the application form needs to be posted.
11.
Stick the Sheet-4 on top of the A4 size envelope and post it.
12.
The packet should reach the corresponding zonal IITs on or before 20th December
2010.
Sheet - 1
IIT COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B311050765 Zone: IIT BOMBAY ZONE Payment Mode: NEFT (UTR _______
_____________ )
1. Name of the Candidate as in PRANAV KUMAR MOHANTY
17. Name of one Parent / ARUN KUMAR MOHANTY
the 10th Class Certificate
Guardian
as in 10th Class Certificate

2. Category
General
18. Place of 10th SchoolingCITY
3.
Gender MALE
19. Type of PreparationSELF STUDY
4. Nationality
INDIAN
20. Board of Qualifying CBSE
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
21. Phone / Mobile 09987223532
Class or Equivalent For the First
Number

Time
22. Mother Tongue Oriya
In the above examination did you Yes
obtain qualifying marks?
23. Pincode or Permanent 400049
6. Earlier Attempts at JEENONE
Place of Residence
24. Parent's / Guardian's Private Service
7. Sub Category
None
Occupation
8.
Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9.
Date of Birth (DD/MM/YYYY) 28/08/1993 26. Parent's / Guardian's Total Above Rs.1
0,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 109 - Mumbai
Cities 112 - Navi Mumbai
12. Counselling
IIT BOMBAY
13. Question Paper Language ENGLISH
I hereby declare that all the particulars stated in this application form are tr
ue to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I al
so certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT
-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in
my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquir
ed is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-
DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of
the Institute I join.
Place:
Date:

Signature of the Candidate


Name of the Parent / ARUN KUMAR MOHANTY
Guardian
Name of the Candidate PRANAV KUMAR MOHANTY

Countersigned by Parent / Guardian


14. Address:-401,MANGAL KIRAN, IRIS PARK LANE, JUHU,MUMBAI
15. Photograph
Please write
your name and
application
number on the
back of photo
before affixing
Signature(within box) in running hand using
Pincode
Phone / Mobile
Number
E-Mail Address
400049
pranavkumarmohanty@hotmail.com
09987223532
Signature of the candidate16.
B311050765 black ball point pen only (do not sign in capitals)
Send this form along with the necessary documents to IIT BOMBAY ZONE
Sheet - 2
CANDIDATE COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B311050765 Zone: IIT BOMBAY ZONE Payment Mode: NEFT (UTR _______
_____________ )
1. Name of the Candidate as in PRANAV KUMAR MOHANTY
17. Name of one Parent / ARUN KUMAR MOHANTY
the 10th Class Certificate
Guardian
as in 10th Class Certificate

2. Category
General
18. Place of 10th SchoolingCITY
3.
Gender MALE
19. Type of PreparationSELF STUDY
4. Nationality
INDIAN
20. Board of Qualifying CBSE
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
21. Phone / Mobile 09987223532
Class or Equivalent For the First
Number

Time
22. Mother Tongue Oriya
In the above examination did you Yes
obtain qualifying marks?
23. Pincode or Permanent 400049
6. Earlier Attempts at JEENONE
Place of Residence
24. Parent's / Guardian's Private Service
7. Sub Category
None
Occupation
8.
Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9.
Date of Birth (DD/MM/YYYY) 28/08/1993 26. Parent's / Guardian's Total Above Rs.1
0,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 109 - Mumbai
Cities 112 - Navi Mumbai
12. Counselling
IIT BOMBAY
13. Question Paper Language ENGLISH
I hereby declare that all the particulars stated in this application form are tr
ue to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I al
so certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT
-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in
my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquir
ed is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-
DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of
the Institute I join.
Place:
Date:

Signature of the Candidate


Name of the Parent / ARUN KUMAR MOHANTY
Guardian
Name of the Candidate PRANAV KUMAR MOHANTY

Countersigned by Parent / Guardian


14. Address:-401,MANGAL KIRAN, IRIS PARK LANE, JUHU,MUMBAI
15. Photograph
Please write
your name and
application
number on the
back of photo
before affixing
Signature(within box) in running hand using
Pincode
Phone / Mobile
Number
E-Mail Address
400049
pranavkumarmohanty@hotmail.com
09987223532
Signature of the candidate16.
B311050765 black ball point pen only (do not sign in capitals)
Sheet - 3
APPLICATION FORM NO
FOR
BY REGISTERED POST/
SPEED POST
B 3 1 1 0 5 0 7 6 5
Rs. 900 /APPLICATION
FORM NO
FOR
BY REGISTERED POST/
SPEED POST
B 3 1 1 0 5 0 7 6 5
Rs. 900 /JEE
-2011

Indian Institutes of Technology

Your Choice
of Cities
for JEE - 2011
Choice - I
109
Choice - II
112
From
Name
Address
Pin
Phone/Mobile:
Email (if any) :
To
The Chairman
Joint Entrance Examination - 2011
Indian Institute of Technology Pin
PRANAV KUMAR MOHANTY
401,MANGAL KIRAN, IRIS PARK LANE, JUHU,MUMBAI
pranavkumarmohanty@hotmail.com
09987223532
4 0 0 0 4 9
IIT BOMBAY, Powai
MUMBAI
4 0 0 0 7 6
IIT BOMBAY ZONE
Sheet - 4
JEE-2011 NEFT Transaction

1. Payee / Beneficiary / Recipient Bank Name : Indian Bank


2. Payee / Beneficiary / Recipient Branch Name : Adyar
3. Bank's IFSC Code: IDIB000A002
4. Payee / Beneficiary / Recipient Name: I I T (MADRAS) JEE-2011 (NEFT A/C)
5. Payee / Beneficiary / Recipient Account No :
910646450
6. Payee / Beneficiary / Recipient Account Type: Current Account
7. Application Fee (Exclusive of other bank
Rs. 900 /

charges):
Please enter your name and application number (B311050765) in the Remitter's Acc
ount Details/Customer
Transaction Details or equivalent fields in the NEFT request form
The counterfoil from bank or confirmation for Internet Transfer (UTR number) sho
uld be attached with this
sheet and sent to IIT
Sheet - 5