Application Form for Online Test Series (BITSAT 2012

)
No. of Test Applied:

1
1

2
No. of Tests

3
Bansalites

4
` 200/` 400/` 600/` 800/-

5
` 300/` 600/` 900/` 1200/` 1500/-

Fee Structure (Inclusive of Service Tax @10.3%)

A-10, “Gaurav Tower”, Road No. 1, I.P.I.A, Kota – 324 005

Are you a ? Bansalite Non Bansalite

Non-Bansalites

www.BansalTestPrep.com
Personal Details

2 3 4 5

` 1000/-

IIT JEE 2012 App. Form # l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l Name : Date of Birth (DD MM YYYY) Father’s Name: Permanent Address: l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l l ___ l ___ l l ___ l ___ l l ___ l ___ l ___ l ___ l Gender: Male Female

l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l PINcode l ___ l ___ l ___ l ___ l ___ l ___ l

Landline with STD Code # l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l Mobile # l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l

0 0

Registration Details on www.BansalTestPrep.com
User ID: Order ID: l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l ___ l

Affix latest Passport Size Colour Photograph

Payment Details
Payment Mode Online Txn. Date / DD Date Amount Online Txn. Reference No. / DD No. / Cash receipt

Online

DD

Cash

# Enclose DD / Cash receipt with this Application in case payment mode is by DD / cash respectively.

Declaration
1. I hereby accept that if I join the institute’s Online Test Series by paying necessary Fee and if I withdraw from the course at any stage, no refund will be made to me. 2. I hereby declare that the information provided by me in the Application Form are true and correct to the best of my knowledge. 3. All disputes are subjected to Kota (Rajasthan) Jurisdiction only.

Date: l ___ l ___ l D D

l ___ l ___ l M M

l ___ l ___ l ___ l ___ l Y Y Y Y Signature (Applicant) Signature (Father/Guardian)

Place: ____________________________________________

Enclosures required for BITSAT Test Series
No. Enclosure Required Check Box

1 2 3

Photocopy of IITJEE 2012 Application Form Photocopy of your I-card (For students of Bansal Classes) or Photocopy of any Photo ID card for Non Bansalites One passport size extra photograph for I-Card Send the completed Application Form along with all required enclosures to the following address: To, The Administrator (Bansal Test Prep) ‘Gaurav Tower’, A-10 Road No. 1, IPIA, Kota-324005, Rajasthan INDIA Mobile : 09571042039