REGISTRATION FORM (or Official use only) Registration No. Altse Form Checks by Employee Code Signature Date Please fill this Form with a Black / Blue pen in BLOCK Letters only ‘Are you already Enrolled / Registered in FITJEE ? If yes, please provide the following info below: 28) Enrollment Number. Registration Number. b)Sudents ID ote Number | NT TAPLEY 1. Details about the Student: Paste your a) Name ofthe Student recort pasoper size ) Date of Birth _(pommmyyvv)_(¢)Gender(v) Mate [_] Female olor photoaraph here «Last Annual Exam / Board Exam Aggregate Marks (3) (© Natonalty Carry one ediional photograph for Hell Ticket 1) Stream you wil pursue after Class Xl {Pease tick (y1): Engineering Nonngineoring: Humanities Fundamental Ste comm Nodical[] other please spect 2. Details to be filled in {for Registration Cent Information Booklet): (@) TestDate aE Ty) (0) Registration Centre Code [~][_] (2. Soar Coe o (0, Sit Cents Code ‘Study Centre, Test Centre & Segment Codes, please refer to point no. 1,2& 3 of relevant (©) Test Cente cove (9 Cm Pree Syigin th Cm ate (a0) I] “nrc C7, a Bm San CN BFC Than Cr a (@)_ How do you want to ocove tho Hal Tick ewei — [_] Printed (Prine al Ticats wb isin ony ts Registration Foon is submited to» FITIEE offen person) 3. Communication Daal: (0) Mal IDs and Mobile Nos. ‘Ea 0 (Pease Flin BLOCK Letters Only). Mobile Number Father Mother Whatieyourprtoredemati ]stxen C]Fater [lMotner Whatisyour prefered Mobie No, []Student []Fatter [Note (©) Correspondence Address: (©) Permanent Address: (Peess menton ont cteren om Ccrespandne Athos) (ease donor write your / you Fathers name in these acess boxes. Fil the aderess only wih the space proued im boxes) ‘4. Details about the School Presently Studying in / Last Attended: (8) School Name & Address ity Town Pin Code State Tel. No. (©) Board (Schoo! s affiated fo) (Your Current Last Clase Rank in your School (4) _ Name of your Schoo! Principal (@) Name of your Subject Teseher: Mathematics yes Bology Chemistry==> 5. Details about Parents (in BLOCK Letters only) Fathers / Legal Guardian Name (Qualification ‘Cccupation. Designation (Office Name / Address, Contact Nos Mother's Name uatitcation Occupation Designation Office Name / Address Contact Nos 6. Dotals o your Senotasic Achievements in any of these exams {Please lick (7) & give its details): mise[]ssroe[ ]moess[] roe] nerf] mpms(] sar otras Detais 7. Are you taking any specialized Cosching fo: Competitive Exams (Please tick(v}}: Yes] No[_] Since (Vea) In¥es, Name of your Coaching Institute Your Overall Rankin your Coaching Institute 8. Dotals about Your Sibling: Name 1 (Brother iste) _______________ ass presenti studying in Name 2 (Brother /Sisto) ngs presenti studying in ‘8. How did you come to know about FITJEE Programs ? {Please tick(v)} NenspaperAdvt. © Goclal Media © News Paper invert © Banner Poster © Website © E-Maller ©. Hoardinge © Ratio Prosont Sx FIITIEE Student © Friends /Rolatves © Through FITJEE Facuty ©. if other source (olease specify) Declaration by the Student / Parent / Guar © we ravarecaveatreatne Tams Cartons pnt maton boc e Test ate rtone gps Peto) is Regstraon Frmandpromiseto ‘bide byhesemo. have so cross vee he Codes iledin above Pali2 and | understancitan error ocersin the registration dus to arong Codes twit be caectod by FITUEE. TestDate, Test Cente Code, Program Code ate cannotna-hangedanrereziatced egetaton Fee wil netbe refunded inany case of taseed io any oer Admission TestDate | authorize FUTIEE, Megacosm (100% Subsidiary of TIEE) , EDFORA Technology Parr of FITIEE) & any other subir of FTJEE o cont to students! ‘carer contact and sand communicatonformat by SME, eal oat on the above mertined communication details given by me ‘+ Incase student reappears FTIEE Tea hi her sdolarshi (awarded ibe scald downy one stab sothat he shedoesnathave any und vonage ver ech appearing sucens ‘¢ FITIEEreservesthe right oer study conte cher tan te one opesby student subject avelbity constants of seats ‘+ Once students granesadmision to he hostel, he il et be permite to witha curing the couse of he academic session and not un wt be made during mid- ‘+ Once stunt ine ud carr fered (ineepecsois/ hr colo of steer opted bore ring), no requestor change of study corre wl be enters, nor ‘Ro coute fee pas lle refundedtunderanyeroanstnces 1 FITIEE eres Deri diag“ anyPrayin, TestDate, Test use, ny Conta ofytaiy ion & CousaF ee witout pornos ‘¢ Toe Rogsterad Offe of FITJEE Lime sat New Dan cate of cpio, students parents ao subj othe exluea icon of appropriate cous n Deli Now Dein ony. Al dpued shel be refered othe Solo Artrsireppoinied by tne Management ct FITJEE Limited. The dao ofthe arivaoreallbe fat & bin. The stave pani shat note sspctted ese beige enoyee ot PITAEE Liar ser cote an reasons ary or kape withecomary. Fee Paid Rs. In Cash (DD /Pay Order No Dated Bank | /we hereby declare that the information furnished on this Registration Form is corect to the best of my knowledge and belie. Date: (Name of Student) ‘Signature of Student) ‘(Wane of Parent/Guardian) ‘Signature of Parent Guardian) National Admissions Office: FITJEE House, 29-A, Kalu Sarai, Sarvapriya Vinar, New Delhi 110 016, Ph 011-49283471/ 73/75 A India TollFroe No," 1800 11 4242 Web: wwwfitje.com