Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: Sf-4 3/82 Notam Appartment Sector 5 Rajendra Nag Ar Sahibabad Ghaziabad Dav Road In Front Of Lal Bahadur Shastri Institute 201005 16. PIN Code: 201005 21. Type of Preparation: Self 23. Board of QE: CBSE 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: Private Sector 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. Ghaziabad (720) II. Gautam Budh Nagar (Noida) (719)
17. Email ID: PATHAK.ARCHIT1993@GMAIL.COM 18. Mobile No: 09971255744 19. Landline No: 01204270516 20. PIN Code of Permanent Residence: 201005 PASTE RECENT COLOR PHOTOGRAPH HERE
Place : ...................... Date : ........................ Name of Parent/Guardian: .............................................................................. Fold Here Candidate Name: Archit Pathak (Signature of the Candidate)
AXIS BANK
( TO BE FILLED IN BY BANK)
JEE COPY
Address: Sf-4 3/82 Notam Appartment Sector 5 Rajendra Nag Ar Sahibabad Ghaziabad Dav Road In Front Of Lal Bahadur Shastri Institute 201005 PIN Code: 201005 Mobile No: 09971255744 Total Payable in Figures (Including Bank Charges): Rs. 1610.00 Total Payable in Words (Including Bank Charges) Rupees:
Application Form No: C27115866 Date of Birth: 19-10-1993 IIT-JEE 2012 Account No: 911020051391279 Challan No: 33043484 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 ROORKEE TO COMPLETE YOUR APPLICATION
AXIS BANK
( TO BE FILLED IN BY BANK)
BANK's COPY
Address: Sf-4 3/82 Notam Appartment Sector 5 Rajendra Nag Ar Sahibabad Ghaziabad Dav Road In Front Of Lal Bahadur Shastri Institute 201005 PIN Code: 201005 Mobile No: 09971255744 Total Payable in Figures (Including Bank Charges): Rs.1610.00 Total Payable in Words (Including Bank Charges) Rupees:
Application Form No: C27115866 Date of Birth: 19-10-1993 IIT-JEE 2012 Account No: 911020051391279 Challan No: 33043484 Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)
........./.........../ 2011
(Authorised Signatory)
JEE COPY
IIT-JEE 2012
C27115866
IIT-JEE 2012
Indian Institutes of Technology
Choice - II
720
719
APPLICATION FORM NO :
C27115866
To
From Name :
Archit Pathak
Address :
Sf-4 3/82 Notam Appartment Sector 5 Rajendra Nag Ar Sahibabad Ghaziabad Dav Road In Front Of Lal Bahadur Shastri Institute 201005
201005 01204270516
Mobile :
09971255744
PATHAK.ARCHIT1993@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.