Professional Documents
Culture Documents
Date of Birth: 30-03-1994 6. Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: Sagar Sadan Machlipul Station Road Sehore 16. PIN Code: 466001 21. Type of Preparation: Self 23. Board of QE: State Board 25. Parents' Educational Background: Both Graduates 27. Annual Income of Parent/Guardian: Rs.1,00,000 - 4,50,000 22. Place of 10th Class Schooling: City 24. Mother Tongue: Hindi 26. Occupation of Parent/Guardian: Public/Govt. Service 3.5 cm x 4.5 cm with the face covering about 75% of the photo 4. Gender: Male 7. Year of Passing 10th Class: 2010 10. Question Paper Language: English 13. Entitled for DS Seat: No 17. Email ID: prakhargjet@gmail.com 18. Mobile No: 09329675294 19. Landline No: 07562225737 20. PIN Code of Permanent Residence: 466001 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: GE 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Indore (210) II. Ujjain (211)
Place : ...................... Date : ........................ Name of Parent/Guardian: .............................................................................. Fold Here Candidate Name: Prakhar Kumar Gupta (Signature of the Candidate)
JEE COPY
Address: Sagar Sadan Machlipul Station Road Sehore PIN Code: 466001 Mobile No: 09329675294 Total Payable in Figures (Including Bank Charges): Rs. 1625.00 Total Payable in Words (Including Bank Charges) Rupees:
CBS Screen No: 8888 Fee Type: 000017 Application Form No: C22110521 Date of Birth: 30-03-1994
Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)
........./.........../ 2011
(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT DELHI TO COMPLETE YOUR APPLICATION
BANK's COPY
CBS Screen No: 8888 Address: Sagar Sadan Machlipul Station Road Sehore PIN Code: 466001 Mobile No: 09329675294 Total Payable in Figures (Including Bank Charges): Rs.1625.00 Total Payable in Words (Including Bank Charges) Rupees: Tran. No / Journal No: Branch Seal (Within the box only) Branch Code: Fee Type: 000017 Application Form No: C22110521 Date of Birth: 30-03-1994
........./.........../ 2011
(Authorised Signatory)
* Challan can be deposited minimum one day after the generation of challan.
JEE COPY
IIT-JEE 2012
C22110521
IIT-JEE 2012
Indian Institutes of Technology
Choice - II
210
211
APPLICATION FORM NO :
C22110521
To
From Name :
Prakhar Kumar Gupta
Address :
Indian Institute of Technology Delhi Hauz Khas, Delhi PIN Code - 110016
466001 07562225737
Mobile :
09329675294
prakhargjet@gmail.com
PLEASE INSERT THE APPLICATION FORM IN THE ENVELOPE IN SUCH MANNER THAT THE BARCODE ON THE APPLICATION FORM IS NOT FOLDED. CHECKLIST FOR THE CANDIDATE
1. Tick the box if you have enclosed the following documents:
a. Completed Application Form with your and parent / guardian's signature. b. Your colour photograph (of size 3.5 cm x 4.5 cm) affixed on application appropriately. c. Attested copy of 10th class certifiate for Date of Birth. d. Attested copy of category certificate if you belong to SC/ST/OBC(NCL). e. Request letter for enlarged font question paper if you have poor vision.
2. Retain a photocopy of the completed application form with you. 3. Send your application form to the IIT as mentioned on the address slip.