Instructions for Candidate:-

1. There are 5 sheets in this file.

2. This sheet (Sheet - 1) is to be retained by you carefully.
3. Your Login id is DUMM0101
4. Remember your password and do not disclose it to anyone.
5. Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to IIT BOMBAY ZONE
a. Stick your color photo at the designated place.
b. Put your signature at the two designated places.
c. Get the signature of your Parent / Guardian at the designated place.
6. Sheet - 3 is the Application Form and should be retained by you for your reference.
7. Sheet - 5 has three copies of a bank challan (Pay-in slip). Take this to the bank when you pay the application fee.
The bank will retain one copy (Bank Copy) of the challan and return two copies to you.Keep one copy (Candidate
Copy)of the challan for your records and attach the third copy (Institution Copy) with the application.

8. Attach attested copies of Tenth Class/SSLC certificate where your date of birth is mentioned clearly, and all other
applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9. Insert completed Application Form with enclosures (if any) into an A4 size envelope. DO NOT FOLD THE
APPLICATION.
10. Sheet - 4 contains the address of the IIT BOMBAY ZONE
to which the application form needs to be posted.
11. Stick the Sheet-4 on top of the A4 size envelope and post it.
12. The packet should reach the corresponding zonal IITs on or before 20th December 2010.

Sheet - 1
 IIT COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B311000001 Zone: IIT BOMBAY ZONE Payment Mode: Bank Challan

1. Name of the Candidate as in DUMMY APPLICANT BANK 17. Name of one Parent / DUMMAY PARENT BANK
the 10th Class Certificate CHALLAN Guardian CHALLAN
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling VILLAGE
3. Gender MALE
19. Type of Preparation SELF STUDY
4. Nationality INDIAN
20. Board of Qualifying CBSE
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 01234567891
Time Number
22. Mother Tongue Sanskrit
In the above examination did you Not Applicable
obtain qualifying marks? 23. Pincode or Permanent 600036
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Others
7. Sub Category PD Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 01/01/1994 26. Parent's / Guardian's Total BELOW Rs.1,00,000
Annual Income
10. Year of passing 10th Class 2003
or Equivalent
11. Choice of Examination 114 - Thane
Cities 107 - Aurangabad
12. Counselling IIT BOMBAY

13. Question Paper Language ENGLISH

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 the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or 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 JEE 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:
Signature of the Candidate
Name of the Parent / DUMMAY PARENT BANK CHALLAN
Guardian
Name of the Candidate DUMMY APPLICANT BANK CHALLAN
Countersigned by Parent / Guardian

14. Address:- ASDF 15. Photograph

GGGF

SSDDD

SSSSSS
Please write
Phone / Mobile 01234567891 your name and
Number application
Pincode 600036 number on the
back of photo
E-Mail Address veezhi@gmail.com before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B311000001 black ball point pen only (do not sign in capitals)
Send this form along with the necessary documents to IIT BOMBAY ZONE

Sheet - 2
 CANDIDATE COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B311000001 Zone: IIT BOMBAY ZONE Payment Mode: Bank Challan

1. Name of the Candidate as in DUMMY APPLICANT BANK 17. Name of one Parent / DUMMAY PARENT BANK
the 10th Class Certificate CHALLAN Guardian CHALLAN
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling VILLAGE
3. Gender MALE
19. Type of Preparation SELF STUDY
4. Nationality INDIAN
20. Board of Qualifying CBSE
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 01234567891
Time Number
22. Mother Tongue Sanskrit
In the above examination did you Not Applicable
obtain qualifying marks? 23. Pincode or Permanent 600036
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Others
7. Sub Category PD Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 01/01/1994 26. Parent's / Guardian's Total BELOW Rs.1,00,000
Annual Income
10. Year of passing 10th Class 2003
or Equivalent
11. Choice of Examination 114 - Thane
Cities 107 - Aurangabad
12. Counselling IIT BOMBAY

13. Question Paper Language ENGLISH

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 the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or 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 JEE 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:
Signature of the Candidate
Name of the Parent / DUMMAY PARENT BANK CHALLAN
Guardian
Name of the Candidate DUMMY APPLICANT BANK CHALLAN
Countersigned by Parent / Guardian

14. Address:- ASDF 15. Photograph

GGGF

SSDDD

SSSSSS
Please write
Phone / Mobile 01234567891 your name and
Number application
Pincode 600036 number on the
back of photo
E-Mail Address veezhi@gmail.com before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B311000001 black ball point pen only (do not sign in capitals)

Sheet - 3
APPLICATION FORM NO B 3 1 1 0 0 0 0 0 1 BY REGISTERED POST/
SPEED POST
FOR Rs. 450 /-

JEE - 2011
Indian Institutes of Technology

Your Choice Choice - I Choice - II

of Cities
for JEE - 2011 114 107

To
From
Name DUMMY APPLICANT BANK CHALLAN
The Chairman
Address Joint Entrance Examination - 2011
Indian Institute of Technology - IIT BOMBAY ZONE
ASDF

GGGF IIT BOMBAY, Powai

SSDDD MUMBAI

SSSSSS

Pin 6 0 0 0 3 6

Phone/Mobile: 01234567891
Email (if any) : veezhi@gmail.com Pin 4 0 0 0 7 6

Sheet - 4
PAY IN SLIP BANK COPY PAY IN SLIP INSTITUTION COPY PAY IN SLIP CANDIDATE COPY

REMITTANCE AT ALL BRANCHES OF REMITTANCE AT ALL BRANCHES OF REMITTANCE AT ALL BRANCHES OF

INDIAN BANK INDIAN BANK INDIAN BANK
Paid in to the credit of INDIAN INSTITUTE OF Paid in to the credit of INDIAN INSTITUTE OF Paid in to the credit of INDIAN INSTITUTE OF
TECHNOLOGY (MADRAS) A/C no 906125068 , ADYAR TECHNOLOGY (MADRAS) A/C no 906125068, ADYAR TECHNOLOGY (MADRAS) A/C no 906125068 , ADYAR
BRANCH CHENNAI, BRANCH CODE : 79 BRANCH CHENNAI, BRANCH CODE : 79 BRANCH CHENNAI, BRANCH CODE :79

Name of the Candidate DUMMY APPLICANT BANK CHALLAN Name of the Candidate DUMMY APPLICANT BANK CHALLAN Name of the Candidate DUMMY APPLICANT BANK CHALLAN

Present Address ASDF GGGF SSDDD SSSSSS - 600036 Present Address ASDF GGGF SSDDD SSSSSS - 600036 Present Address ASDF GGGF SSDDD SSSSSS - 600036
in CAPITAL LETTERS in CAPITAL LETTERS in CAPITAL LETTERS
with Pin Code with Pin Code with Pin Code

Date of Birth 01/01/1994 Date of Birth 01/01/1994 Date of Birth 01/01/1994

Mobile / Landline No: 01234567891 Mobile / Landline No: 01234567891 Mobile / Landline No: 01234567891

E Mail ID veezhi@gmail.com E Mail ID veezhi@gmail.com E Mail ID veezhi@gmail.com

Category : General Category : General Category : General

Amount : Rs. 450 /- Amount : Rs. 450 /- Amount : Rs. 450 /-

Amount in words : Rupees Four Hundred And Fifty Only. Amount in words : Rupees Four Hundred And Fifty Only. Amount in words : Rupees Four Hundred And Fifty Only.
(*Inclusive of Bank Charge) (*Inclusive of Bank Charge) (*Inclusive of Bank Charge)
Name of the Name of the Name of the
Receiving Branch Receiving Branch Receiving Branch

Signature of the candidate Signature of the candidate Signature of the candidate

FOR BANK’S USE FOR BANK’S USE FOR BANK’S USE

Journal No: Branch Journal No: Branch Journal No: Branch

Code Code Code

Application B311000001 Signature Application B311000001 Signature Application B311000001 Signature

Number : of Number : of Number : of
cashier cashier cashier

Branch Date Branch Date Branch Date

Name Name Name

Sheet - 5