Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: Rz-26/P 45 -1a Street No. 8 Indra Park Ext. Palam Colony New Delhi 16. PIN Code: 110045 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: Public/Govt. Service 3.5 cm x 4.5 cm with the face covering about 75% of the photo 4. Gender: Female 7. Year of Passing 10th Class: 2010 10. Question Paper Language: English 13. Entitled for DS Seat: No 17. Email ID: smart.priyarai@gmail.com 18. Mobile No: 09582779180 19. Landline No: 01125051626 20. PIN Code of Permanent Residence: 110045 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: GE 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Delhi (West) (202) II. Delhi (North) (203)
Place : ...................... Date : ........................ Name of Parent/Guardian: .............................................................................. Cut Here (Signature of the Candidate)
SEND THE UPPER PART TO JEE OFFICE IIT DELHI TO COMPLETE YOUR APPLICATION
JEE COPY
IIT-JEE 2012
C22315214
IIT-JEE 2012
Indian Institutes of Technology
Choice - II
202
203
APPLICATION FORM NO :
C22315214
To
From Name :
Priyanka Rai
Address :
Rz-26/P 45 -1a Street No. 8 Indra Park Ext. Palam Colony New Delhi
Indian Institute of Technology Delhi Hauz Khas, Delhi PIN Code - 110016
110045 01125051626
Mobile :
09582779180
smart.priyarai@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.