Auth Code: f68131ee3bb6b7a436548626dcc8ecf6 1. Candidate Name: Manoj Kumar Rath 2. Parent/Guardian Name: Rajendra Rath 3.

Date of Birth: 28-06-1995 6. Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: C/O- Rajendra Rath At/Po- Indiranagar 2nd Lane, Rayagada. Dist- Rayagada State- Odisha 16. PIN Code: 765001 21. Type of Preparation: Self 23. Board of QE: State Board 25. Parents' Educational Background: Only One Graduate 27. Annual Income of Parent/Guardian: Rs.1,00,000 - 4,50,000 22. Place of 10th Class Schooling: Town 24. Mother Tongue: Oriya 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 5. Category: GE 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Berhampur (511) II. Visakhapatnam (502)

17. Email ID: manojkumar.rath95@gmail.com 18. Mobile No: 09437235225 19. Landline No: 06856223181 20. PIN Code of Permanent Residence: 765001 PASTE RECENT COLOR PHOTOGRAPH HERE

DECLARATION BY THE CANDIDATE

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read IIT-JEE 2012 Information Brochure (given on IIT-JEE Website) and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2010 or earlier and neither taken admission nor paid the registration fee at any of the IITs / IT-BHU / 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 IIT-JEE 2012 and if already admitted, my admission / degree acquired 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 : ........................ Name of Parent/Guardian: .............................................................................. Fold Here Candidate Name: Manoj Kumar Rath (Signature of the Candidate)

Candidate Signature (Sign within the box only)

(Countersigned by Parent/Guardian) Fold Here

STATE BANK OF INDIA

( TO BE FILLED IN BY BANK)

JEE COPY

Address: C/O- Rajendra Rath At/Po- Indiranagar 2nd Lane, Rayagada. Dist- Rayagada State- Odisha PIN Code: 765001 Mobile No: 09437235225 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: C25115489 Date of Birth: 28-06-1995

Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)

One Thousand Six Hundred and Twenty Five Only

Date of Deposit: (Signature of the Candidate)

........./.........../ 2011

(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT KHARAGPUR TO COMPLETE YOUR APPLICATION

Candidate Name: Manoj Kumar Rath

STATE BANK OF INDIA

( TO BE FILLED IN BY BANK) ( CASH CAN BE TENDERED AT ANY SBI BRANCH. )

BANK's COPY

CBS Screen No: 8888 Address: C/O- Rajendra Rath At/Po- Indiranagar 2nd Lane, Rayagada. Dist- Rayagada State- Odisha PIN Code: 765001 Mobile No: 09437235225 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: C25115489 Date of Birth: 28-06-1995

One Thousand Six Hundred and Twenty Five Only

Date of Deposit:

........./.........../ 2011
(Authorised Signatory)

(Signature of the Candidate)

* Challan can be deposited minimum one day after the generation of challan.

JEE COPY

IIT-JEE 2012

INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012

Application Form No.

C25115489

IIT-JEE 2012
Indian Institutes of Technology

BY REGISTERED POST / SPEED POST ONLY

Application Form No.

Choice - I Your Choice of Examination Cities

Choice - II

511

502

APPLICATION FORM NO :

C25115489
To

From Name :
Manoj Kumar Rath

The Chairman Joint Entrance Examination 2012

Address :

C/O- Rajendra Rath At/Po- Indiranagar 2nd Lane, Rayagada. Dist- Rayagada State- Odisha

Indian Institute of Technology Kharagpur Kharagpur PIN Code - 721302

PIN Code : Landline : Email :

765001 06856223181

Mobile :

09437235225

manojkumar.rath95@gmail.com

CUT HERE AND PASTE THE UPPER PART ON A5 ENVELOPE

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.