KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams

Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

Application Form
(Target Exam IITJEE/AIEEE/AIPMT)
Latest Photograph

Course Applying For

Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij E - 13 E-12 E-11 M-13 M-12 M-11 B-12 B-12 F-10 F-9 PCM PCB

1.Name of the Applicant

2.Fathers Name

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

3.Mothers Name
4. State of Domicile

5.Date of Birth Date Month Year

6.Gender Male Female

7.Category General OBC SC ST DS PD

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

8.Religion

9.Permanent Address

10.Address of Correspondence (All study materials and test papers will be sent at this address) with phone/mobile number

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

11.Medium of Studies to be opted in Kshitij Education India Hindi English

12.Past Performance in Competitive/Talent Examinations, fill if relevalent

S. No Competitive Or Talent Examination Year (Qualified) Level Qualified (1/2/Final) Max Marks Marks Obtained % Marks Remarks, if any

(AIR)

(ASR)

1.

NTSE Olympiads KVPY IITJEE AIPMT AIEEE Other

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

2.
3. 4. 5. 6. 7.

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

13.Parents/Guardians Occupation

14.Past four years Acadmic Performance

Class Year of Passing Out Name of the School City/Town/Village District State Board % Marks/Grade Aggregate % Marks/Grade in PCM/B

12

11

10

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

15. Address and Phone No. of Class 10 School

16.Address and Phone No. of Class 12 School

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

17.Emergency Mobile No./Email (other than Parents) Name Mobile No. Email

18.How did you come to know about Kshitij Education India? (Write in 30 words)

19.Parents/Guardians Bank Account Detail

Account Relationship Account Bank Holders with Number name Student City Branch

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

KSHITIJ EDUCATION INDIA

FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

Declaration
I/We undersigned, hereby assure that the information given in the application form (as well as in all relevant documents i.e. Cheques, Demand Drafts etc.) is true and correct. I/We have understood and agreed that my misrepresentation or concealment of facts will justify the denial/cancellation of undesired students admission, or expulsion from the institute at any stage of the academic session.I have read and hereby provide my/our free consent to the terms and conditions of application form and mentioned on the website for admission is the institute for the academic session 2012-2013 further, if undersigned is admitted I/We promise to abide by all the rules and regulations and norms of discipline of the institute as long as undersigned student remains a registered student of Kshitij Education India. I/We hereby also declare that while being an enrolled student of Kshitij Education India, undersigned student will be responsible in terms of providing relevant details of all the competitive examination (in form of true photocopies of the application form of the relevant examination) while he/she will be appearing in the future by virtue of coaching and academic support from the institute. If the undersigned student, as registered student succeeds in any of these competitive examination, Kshitij Education India will have all the rights of using his/her result, photo graph and testimonials in any form for its growth strategies and development plans. In such cases I/We never have any objection or protest for this.

Signature of Student Date:Place:-

Signature of Parent Date:Place:-

Note:- In case of any dispute, the Jurisdiction of the Court of Delhi will be applicable

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045 Contact No. 011 64599348, 011 64739348, 011 64599348, 011 65659348 Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com