For School / Co-ordinator's use only For Office use only

Please fill this Form in CAPITAL LETTERS, in ENGLISH and in BLACK INK only.

Name
( Write your name you would like to be printed on the certificate )
TELL US ABOUT YOURSELF

Address Flat/Block No. & Name of Premises / Building

Road / Street / Lane / Post Office

Area / Locality / Taluka / Sub-Division / Landmark

Town / City / District

State / Union Territory PIN

Std Gender (M/F) Date of Birth - -

( d d m m y y y y )
Medium (E/M E=English, M=Marathi )

Father's Name
TELL US ABOUT
YOUR PARENTS

Educational Qualifications

Mother's Name
Educational Qualifications

Tel. No.
(STD Code) (Mobile No.)
e-mail ID
In case you want the cheque for your prize money due, if any, in a name other than yours, please furnish :
PAYEE

Name of the person in whose name

the cheque is to be drawn

Name
TELL US ABOUT YOUR SCHOOL

Address Flat/Block No. & Name of Premises / Building

Road / Street / Lane / Post Office

Area / Locality / Taluka / Sub-Division / Landmark

Town / City / District

State / Union Territory PIN

Tel. No. Fax No.

(STD Code)
e-mail ID

Amount I have paid as under : (Please tick the appropriate box below )
Maths Talent Search Examination Fee Rs. 200
Model Question Papers for Maths Talent Search Exam Rs. 40
Previous MTSE Question Papers ( at Rs. 10 each) Rs.
TELL US ABOUT
YOUR PAYMENT

Courier Charges (Rs. 20 / 25 for one set of Book and Papers) Rs.
Mode Please tick the appropriate box below : Total Rs.
I have paid cash Rs. ___________ to my teacher / co-ordinator / office.
I am sending Pay Order / Demand Draft No. ______________ dated ____________ for Rs. ___________
drawn on _____________________________________________ (Bank) , Branch ____________________
in favour of Indian Institute for Studies in Mathematics, payable at Mumbai.
I have deposited cheque for Rs. in Branch of Punjab National Bank in A/c. No. 3736002101016736
or Branch of HDFC Bank in A/c. No. 05012020000872. Original Pay-in-Slip is affixed.
In cash deposit, add Rs. 25 for Punjab National Bank or Rs. 60 for HDFC Bank as bank charges.
PLEASE

I solemnly declare that what is stated above and overleaf is true and correct to the best of my knowledge and information.
VERIFY

(Signature of parent/guardian) TAKE A PHOTOCOPY OF THIS FORM BEFORE SUBMISSION (Signature of student)
(Subject to Mumbai jurisdiction)
11 Arihant Mansion, 1st Floor, 29 Keshavji Nayak Road, Bhat Bazar, Masjid (W), Mumbai 400009. Tel : (022) 66355150 www.iisma.com