Auth Code: 084556ced6f33960b8244d6dfbcecb98 1. Candidate Name: Priyanka Rai 2. Parent/Guardian Name: Mr Sushil Rai 3. Date of Birth: 30-10-1993 6.

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)

DECLARATION BY THE CANDIDATE

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 IIT-JEE 2012 Information Brochure (given on IIT-JEE Website) and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2010 or earlier and neither taken admission nor paid the registration fee at any of the IITs / IT-BHU / 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 IIT-JEE 2012 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 : ........................ Name of Parent/Guardian: .............................................................................. Cut Here (Signature of the Candidate)

Candidate Signature (Sign within the box only)

(Countersigned by Parent/Guardian) Cut Here

SEND THE UPPER PART TO JEE OFFICE IIT DELHI TO COMPLETE YOUR APPLICATION

JEE COPY

IIT-JEE 2012

INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012

Application Form No.

C22315214

IIT-JEE 2012
Indian Institutes of Technology

BY REGISTERED POST / SPEED POST ONLY

Application Form No.

Choice - I Your Choice of Examination Cities

Choice - II

202

203

APPLICATION FORM NO :

C22315214
To

From Name :
Priyanka Rai

The Chairman Joint Entrance Examination 2012

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

PIN Code : Landline : Email :

110045 01125051626

Mobile :

09582779180

smart.priyarai@gmail.com

CUT HERE AND PASTE THE UPPER PART ON A5 ENVELOPE

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.