PAPER APPLICATION FORM

Transcription

1 PAPER APPLICATION FORM (for Admission Test in March, April & May, 2011) Please fill this Paper Application Form with a black / blue pen in BLOCK Letters only. Paste your recent passport size color photograph here and attach one additional photograph with this Paper Application Form for the Hall Ticket 1. (a) Have you appeared in any FIITJEE test for the academic year 2011? If yes, please provide your Number: (b) If you do not remember the Number, please provide the Mobile / Tel. No. provided at the time of (Please do not fill anything here, if you are registering for the first time). 2. Details about Program: {for Program Code, Code, Code & Test Code, please refer to point no. 7(a), 7(b), 8 & 9} (a) Admission Test Date D D M M (b) Code (c) Program Code (d) Code (e) Test Code (f) Class Studying in the Academic Year {e.g. fill Class 8 as 08} 3. Details about the Student: (a) Name of the Student Gender ( ): Male Female (b) Father s Name. (c) Date of Birth (DD/MM/YYY). (d) Nationality:. (e) Last School annual Exam / Board Exam Aggregate Marks (%). 4. Communication Details: (a) Mobile No (b) ID. (c) Correspondence Address.. Pin Code. State. Tel No. (d) Permanent Address.. Pin Code. State. Tel No. 5. Details about the School Presently Studying in: (a) School Name & Address.. Pin Code. Tel No:. (b) Board (School is affiliated to). 6. Fee Payment Details : Amount (Rs). Mode (Cash / DD / Pay Order). DD / Pay Order No.. DD / Pay Order Date. Issuing Bank Name. Declaration by the Student / Parent / Guardian I have read the Terms & Conditions printed in this Paper Application Form and agree to abide by the same. I have also cross verified the Codes filled in above Point 2 and I understand if an error occurs in the registration due to wrong codes it will not be corrected by FIITJEE. Test Date, Test, Program Code etc. can not be changed once registered. I authorize FIITJEE to contact and send information by sms, , post on the above mentioned communication details given by me. Date:.. (Signature of the Student) (Signature of the Parent / Guardian) 1

2 7 (a). Program Codes {to be filled in point no. 2 (c) of this Paper Application Form} : Program Code Program Name Select Eligibility 6051 LITTLE GENIE - One Year Foundation Program - Regular Week 6053 LITTLE GENIE - One Year Foundation Program - Sunday Contact Classes Class VI 7010 UDAYA Plus - Two Year Integrated School Program 7051 UDAYA - Two Year Classroom Program for NTSE - Regular Contact Classes 7052 UDAYA - Two Year Classroom Program for NTSE - Weekend Contact Classes 7053 UDAYA - Two Year Classroom Program for NTSE - Sunday Contact Classes 8051 UDAYA - One Year Classroom Program for NTSE - Regular Week Contact Classes 8052 UDAYA - One Year Classroom Program for NTSE - Weekend Contact Classes 8053 UDAYA - One Year Classroom Program for NTSE - Sunday Contact Classes 9015 Excellent Schooling Program 9020 SUPREME - Four Year Integrated School Program 9061 FOUR YEAR Classroom Program for IIT-JEE - Regular Week Contact Classes 9062 FOUR YEAR Classroom Program for IIT-JEE - Weekend Contact Classes 9063 FOUR YEAR Classroom Program for IIT-JEE - Sunday Contact Classes 9021 USA UnivQuest - Four Year Integrated School Program 9042 USA UnivQuest - Four Year Classroom Program 1015 Excellent Schooling Program 1061 Three Year Classroom Program - Regular Week Contact Classes 1062 Three Year Classroom Program - Weekend Contact Classes 1063 Three Year Classroom Program - Sunday Contact Classes 1042 USA UnivQuest - Three Year Classroom Program 1110 PINNACLE - Two Year Integrated School Program for IIT-JEE 1151 Two Year Classroom Program for IIT-JEE - Regular Week Contact Classes 1152 Two Year Classroom Program for IIT-JEE - Weekend Contact Classes 1153 Two Year Classroom Program for IIT-JEE - Sunday Contact Classes 1154 Two Year Classroom Program for IIT-JEE - Special Weekend Classes 1111 USA UnivQuest -Two Year Integrated School Program 1142 USA UnivQuest -Two Year Classroom Program 1251 One Year Classroom Program for IIT-JEE - Regular Week Contact Classes 1252 One Year Classroom Program for IIT-JEE - Weekend Contact Classes 1253 One Year Classroom Program for IIT-JEE - Sunday Contact Classes 1254 One Year Classroom Program for IIT-JEE - Regular Week + Sunday Contact Classes 1351 One Year Extended Classroom Program for IIT-JEE - Regular Week Contact Classes Note : Not all program variations / programs will be available at all FIITJEE s. Please contact your respective FIITJEE for availability of program and its variations. 7 (b). Please tick () for admission to FIITJEE World School at Hyderabad Financial Assistance Eligibility Test Program Code Program / Segment Select 6014 Admission to Class VI of FIITJEE World School 7014 Admission to Class VII of FIITJEE World School 8014 Admission to Class VIII of FIITJEE World School 9014 Admission to Class IX of FIITJEE World School Class VII Class VIII Class IX Class X Class XI Class XII for XII Appeared / Pass Students 8. / Codes {to be filled in point no. 2 (b) & 2 (d) of this Paper Application Form} : CENTRE CENTRE Delhi (Dwarka) 10 Amritsar 17 Delhi (East) 13 Bangalore 55 Delhi (Janak Puri) 14 Bhilai 46 Delhi (Punjabi Bagh) 12 Bhopal 47 Delhi (Rohini) 15 Bhubaneswar 73 Delhi (South) 11 Bokaro 83 Delhi NCR (Faridabad) 19 Chandigarh 16 Delhi NCR (Gurgaon) 18 Chennai (Adyar) 62 Delhi NCR (Noida) 21 Chennai (Kilpauk) 61 2

3 CENTRE CENTRE Chennai (Sriperumbudur) 63 Mumbai (Dadar) 41 Coimbatore 64 Mumbai (Kandivali) 44 Dhanbad 84 Mumbai (Navi Mumbai) 45 Durgapur 74 Mumbai (Thane) 40 Hyderabad (Dilsukhnagar) 52 Nagpur 49 Hyderabad (Kukatpally) 53 Patna 81 Hyderabad (Saifabad) 51 Pune 39 Indore 48 Raipur 38 Jaipur (J.L.N. Marg) 27 Ranchi (Lalpur) 82 Jaipur (Vaishali) 32 Ranchi (S. O. P.) 85 Kanpur 24 Shaktinagar_NTPC 23 Kolkata (Rabindra Sadan) 71 Vadodara 33 Kolkata (Ultadanga-Salt Lake) 72 Varanasi 25 Lucknow 22 Visakhapatnam 54 Mumbai (Andheri) 42 FIITJEE World School, Hyderabad Mumbai (Chembur) Test Codes {to be filled in point no. 2 (e) of this Paper Application Form} : Test DD / Pay Order Payable at * Amritsar - FIITJEE Ltd., SCO - 31, 3rd Floor, District Shoping, Ranjit Avenue B-Block Amritsar 170 Bangalore - Saint Joseph Indian High School, Near Mallya Hospital, Vittal Mallya Road Bangalore 551 Bhilai - MGM School, Sector 6 Bhilai 462 Bhopal - FIITJEE Ltd., 48 A, 3rd Floor, Gurukripa Plaza, M.P.Nagar, Zone-2 Bhopal 470 Bhubaneswar - FIITJEE Ltd., Bharat Scouts & Guides Complex, Scouts Bhawan, 2nd Floor, C - IX / 8, Unit 3 Bhubaneswar 730 Bokaro - Bokaro Public School, Sec-3/C, B.S. City Bokaro 968 Chandigarh - Manav Mangal School, Sector 21 (Test for all Admission Test dates except 17th April, 2011) Chandigarh 167 Code Chandigarh (Mohali) - Manav Mangal School, Setor - 64, Mohali, Punjab (Test for Admission Test date 17th April, 2011 only) Mohali 168 Chennai (North Central) - Maharishi Vidya Mandir Sr. Sec School, No. 28, Dr. Gursamy Rd, Chetpet Chennai 611 Chennai (South) - Kumararani Meena Muthiah Matriculation Hr Sec School, No:4, Crescent Avenue Road, Gandhi Nagar, Adyar Chennai 623 Chennai (Sriperumbudur) - Maharishi International Residential School, Santhavelur, Sunguvar Chathiram Chennai 613 Chennai (Valasaravakkam) - Devi Academy Senior Secondary School, Plot No.1/E-1, Door No. 7, Alapakkam Road, Chennai 637 Coimbatore - Suguna PIP School, Nehru Nagar, Kalapatty Road, (Adjacent ot Suguna Polytechnic), Coimbatore Chennai 640 Delhi (Dwarka) - D.A.V. Public School, Sector - 6, Dwarka Delhi 101 Delhi (East) - Lovely Public Senior Secondry School, Priyadarshini Vihar Delhi 131 Delhi (North West) - M.M. Public School, Vasudha Enclave, Pitampura (Test for all Admission Test dates except 15th May, 2011) Delhi (North West) - Richmond Global School, Near NS Road, Mianwali Nagar, Paschim Vihar (Test for Admission Test date 17th April, 2011 only) Delhi 125 Delhi 128 Delhi (North West) - Mount Abu School, Sector 5 Rohini, Near Rithala Metro Station (Test for Admission Test date 15th May, 2011 only) Delhi 153 Delhi (South) - Suraj Bhan D.A.V. Public School, F - 10/15, Poorvi Marg, Vasant Vihar Delhi 112 Delhi (West) - Kamal Public School, D - Block, Vikaspuri, New Delhi (Test for Admission Test dates 3rd April & 1st May, 2011 only) Delhi 127 Delhi (West) - FIITJEE Ltd., B-1, 623, 2nd Floor, At District Crossing, Janak Puri (Test for all Admission Test dates except 3rd April & 1st May, 2011) Delhi 140 Delhi NCR (Faridabad) - D.A.V. Public School, Sector 37, Faridabad Delhi 114 Delhi NCR (Ghaziabad) - D.A.V. Public School, Sector-II, Rajinder Nagar, Sahibabad, Ghaziabad (Test for all Admission Test dates except 27th March, 2011) Delhi 134 Delhi NCR (Gurgaon) - Blue Bells Model School, Sector-4 Delhi 182 Delhi NCR (Noida) - Khaitan Public School, Sector 40 Delhi 212 Dhanbad - Delhi Public School, Karmik Nagar, P.O. - I.S.M. Dhanbad 832 Durgapur - D.A.V. Model School, J. M. Sengupta Road, West Bengal Durgapur 713 Hyderabad (Dilsukhnagar) - FIITJEE Ltd., D.No.: /6/2/2, Opp: Sashi Hospital Hyderabad 520 3

4 Test DD / Pay Order Payable at * Hyderabad (Kukatpally) - FIITJEE Ltd., H.No.22-97, Plot No.1, Opp. Patel Kunta Huda Park, Vijaynagar Colony Hyderabad 530 Hyderabad (Saifabad) - FIITJEE Ltd., # /B, Opp. Secretariat, Saifabad Hyderabad 510 Indore - FIITJEE Ltd., 27, 2nd Floor, Scheme 54, Opp. Orbit Mall, PU-3 Commerical Bhamori, AB Road Indore 480 Jaipur - FIITJEE Ltd., 3A, DL Tower, Vidyasharam Institutional Area, JLN Marg Jaipur 270 Kanpur - FIITJEE Ltd., 16/116, Karmin Arcade (Opp to Income Tax Office), Civil Lines Kanpur 240 Karnal - Brahmanand Public School, Sector-8 (Test for Admission Test dates 3rd & 17th April, 2011 only) Delhi 123 Kolkata - J.J. Ajmera School, 12B Hetshyam Road Kolkata 711 Code Lucknow - FIITJEE Ltd., Scholars Home, Inter College, Vipul Khand-3, Gomti Nagar (Test for all Admission Test dates except 15 th & 22 nd May, 2011) Lucknow 220 Lucknow - The Awadh School, 5/6, Vipul Khand, Gomti Nagar (Test for Admission Test date 15 th & 22 nd May, 2011 only) Lucknow 226 Mumbai (Andheri) - FIITJEE Ltd., GF Baba House, Andheri Kurla Road, Off Western Express Highway, Andheri (E) Mumbai 420 Mumbai (Chembur) - FIITJEE Ltd., Ujagar Complex, Opposite Deonar Bus Depot, Off Sion Trombay Road, Deonar, Chembur Mumbai 430 Mumbai (Kandivali) - Thakur Vidya Mandir High School & Junior College of Science & Commerce, Thakur Complex, Kandivali (E) Mumbai 440 Mumbai (Navi Mumbai) - FIITJEE Ltd., B-500, 2nd Floor, Vashi Plaza, Plot No , Sector-17, Vashi, Mumbai 450 Mumbai (Sion) - Little Angels High School, Opp Gandhi Market, Adjacent King Circles Station, Sion (W) Mumbai 411 Mumbai (Thane) - FIITJEE Ltd., 2nd Floor, Evershine Mall (Prabhat Plaza), Opp M H High School, Station Road, Thane (W) Mumbai 400 Nagpur - FIITJEE Ltd., FIITJEE Tower, 210, Opp. Children s Traffic Park, Dharampeth Nagpur 490 Patna - B. D. Public School, Buddha Colony, Near Buddha Colony, Thana (Test for Admission Test dates 27th March & 3rd April, 2011 only) Patna - Leeds Asian School, Nahar Chowk, Jeet Narayan Path, Beily Road (Test for all Admission Test dates except 27th March & 3rd April, 2011) Pune - FIITJEE Ltd., 3rd Floor, Vega, Swargate, Shankarsheth Road, Gultekadi, Pune (Test for all Admission Test dates except 1st May, 2011) Patna 813 Patna 998 Pune 390 Raipur - Gyan Ganga Educational Academy, Raipur, 11 KM, Vidhan Sabha Mark, Raipur Bhilai 463 Ranchi - FIITJEE Ltd., Samriddhi Complex, Ground Floor, SOP, Doranda, Ranchi Ranchi 850 Ranchi - St. Aloysius School, Purulia Road (Test for all Admission Test dates except 27th March, 2011) Ranchi 989 Rohtak - Model School, Company Bagh, Rohtak (Test for Admission Test dates 3rd & 17th April, 2011 only) Rohtak 124 Shaktinagar_NTPC - FIITJEE Ltd., Employee Development, Hostel No.-3 NTPC, Dist.Sonebhadra Shaktinagar 230 Vadodara - Alembic Vidyalaya, Alembic Colony, Gorwa Road Vadodara 911 Varanasi - FIITJEE Ltd., B-38/IK, Mahmoor Ganj Varanasi 250 Visakhapatnam - FIITJEE Ltd., , Plot No. 87, Opp. Nehru Bazaar, Dwarkanagar Visakhapatnam 540 * If Fee is paid through Demand Draft / Pay Order How to Register for Admission Test Please note that before you start your registration, you know the Pin Code of the postal address of the school where the student is studying in. To make the registration process simple we have worked out various options for registration. Option 1 (e-application) : This is an ideal mode of registration for all the students. You can register from the convenience of your home or office and if you do not have internet facility you can still register at a cybercafé. Log on to our online registration portal and file your application online using this option and take a printout of your e-application from the portal. After this Please deposit it (in person only) at any FIITJEE with the registration fee in Cash or Demand Draft / Pay Order, with two passport size colour photographs and proof of studying in your class. (Last Date to submit your e-application at FIITJEE in person is Two days before the Test Date). Your Hall ticket will be issued on the spot by FIITJEE. You can also send your e-application form along with a Demand Draft / Pay Order, with two passport size colour photographs by courier to the controlling FIITJEE centre provided at the website. (Last date to receive your e-application by post is One week before the Test Date). Your Hall ticket will be issued by the controlling FIITJEE and will be send by courier to you. Option 2 (On-line Payment): If you have Master/ Visa (Credit / Debit) card registered for online transactions with the issuing bank you can choose this option for registration. You can pay the prescribed test fee using secured AXIS Bank s Payment Gateway and print your Hall Ticket on-line. Please ensure that you paste your recent passport size colored photograph on to the hall ticket and get it validated during the examination. (Last date to register by On-line Payment is Two days before the Test Date). Option 3 (Paper Application) : For a higher data accuracy and easy declaration of result we recommend you to register online however if it is just impossible for you to register online you can register through Paper Application form. Fill in your complete details in the Paper Application form and submit it to the nearest FIITJEE along with the prescribed test fee in cash/ by Demand Draft or Pay order with two passport size Colour photographs & proof of studying in your class and collect your Hall Ticket from the FIITJEE. You can also send your Paper Application form along with a Demand Draft / Pay Order by courier to your nearest FIITJEE. (Last date to receive your Paper Application Form by post is One week before the Test Date). Your Hall ticket will be issued by the FIITJEE and will be send by courier to you. For Option 1 & Option 3 the test fee can also be paid by DD / Pay Order. The DD / Pay Order should be in favor of FIITJEE LTD. Open Test, Aptitude Test etc. A/C, payable at respective locations mentioned against the Test centers in the Test Centers list in the Paper Application Form. For DDs / Pay Orders payable at Ranchi it should be favoring FIITJEE (Ranchi Classes) Ltd. and for DDs / Pay Orders payable at Hyderabad it should be favoring FIITJEE (Hyderabad Classes) Ltd. 4

5 Admission Test Dates and Fee for all FIITJEE s (except for Hyderabad & Visakhapatnam s) : Admission Test Dates Fee Early Benefit with Normal Fee with Late Fee For Class VI, VII, VIII Rs. 300/-* Appeared/pass Rs. 500/-* For Class VI, VII, VIII Rs. 650/-* Appeared/pass Rs. 1000/-* For Class VI, VII, VIII Rs. 1000/- * Appeared/pass Rs. 2000/- * 27th March, 2011 Till 12th March, 2011 From 13th March to 22nd March, 2011 From 23rd March to 25th March, rd April, 2011 Till 15th March, 2011 From 16th March to 29th March, 2011 From 30th March to 1st April, th April, 2011 Till 20th March, 2011 From 21st March to 12th April, 2011 From 13th April to 15th April, st May, 2011 Till 3rd April, 2011 From 4th April to 26th April, 2011 From 27th April to 29th April, 2011 # 15th May, 2011 Till 17th April, 2011 From 18th April to 10th May, 2011 From 11th May to 13th May, nd May, 2011 Till 24th April, 2011 From 25th April to 17th May, 2011 From 18th May to 20th May, th May, 2011 Till 1st May, 2011 From 2nd May to 24th May, 2011 From 25th May to 27th May, 2011 # Test Date for Chennai & Coimbatore Test s only Financial Assistance Eligibility Test (FAET) Dates and Fee for Hyderabad & Visakhapatnam s only : FAET Dates Fee Early Benefit with Normal Fee with Late Fee For Class VI, VII, VIII Rs. 300/-* Appeared/pass Rs. 500/-* For Class VI, VII, VIII Rs. 650/-* Appeared/pass Rs. 1000/-* For Class VI, VII, VIII Rs. 1000/- * Appeared/pass Rs. 2000/- * 27th March, 2011 Till 12th March, 2011 From 13th March to 22nd March, 2011 From 23rd March to 25th March, th April, 2011 Till 16th March, 2011 From 17th March to 5th April, 2011 From 6th April to 8th April, th April, 2011 Till 20th March, 2011 From 21st March to 12th April, 2011 From 13th April to 15th April, th April, 2011 Till 27th March, 2011 From 28th March to 19th April, 2011 From 20th April to 22nd April, th May, 2011 Till 10th April, 2011 From 11th April to 3rd May, 2011 From 4th May to 6th May, th May, 2011 Till 17th April, 2011 From 18th April to 10th May, 2011 From 11th May to 13th May, nd May, 2011 Till 24th April, 2011 From 25th April to 17th May, 2011 From 18th May to 20th May, th May, 2011 Till 1st May, 2011 From 2nd May to 24th May, 2011 From 25th May to 27th May, 2011 * Fee is inclusive of Service Tax. The Fee can also be paid in cash in person only at FIITJEE. Students registering for Admission Test can download Free Sample Papers from our website. Log on to with your Number and Web Access Code as printed on the Admission Test Hall Ticket. Please ensure that you enter your correct details on the website. In case a student reappears in FIITJEE Test, his / her scholarship (if awarded) will be scalded down by one slab so that he / she does not have any undue advantage over fresh appearing students. I hereby declare that the information furnished on this Paper Application Form are correct to the best of my knowledge and belief. Date: Place: (Signature of the Student) (Signature of the Parent / Guardian) Note 1 : FIITJEE reserves the right to offer any study centre, other than the one opted by the student, subject to availability / constraints of seats. Note 2 : Once admission is granted to the hostel, students will not be permitted to withdraw during the course of the academic session and no refund will be made during mid session. Note 3 : fee will not be refunded in any case or transferred to any other Admission Test Date. Note 4 : Once a student joins the study centre offered, (irrespective of his / her choice of study centre before joining) no request for change of study centre will be entertained, nor will the course fee paid be refunded under any circumstances. Note 5 : FIITJEE reserves the right to change / cancel any program, test date, test centre, eligibility criterion & course fee without prior notice. Note 6 : The Registered Office of FIITJEE Limited is at New Delhi. In case of dispute, students / parents are subject to the exclusive jurisdiction of appropriate courts in Delhi / New Delhi only. All disputes shall be referred to the Sole Arbitrator appointed by the Management of FIITJEE Ltd. The decision of the arbitrator shall be final & binding. The arbitrator so appointed shall not be incapacitated for reasons of their being the employee of FIITJEE Ltd. or its sister concern, and for reasons of having any prior linkage with the company. 5

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