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    Application

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    Prasanna Vangara
    This document contains an application form for the JEE 2012 entrance exam. It includes personal details of the candidate such as name, date of birth, address, photo, academic details, declaration of truthfulness, and payment receipt details. The candidate is Vangara Taraka Sai Pavan from Andhra Pradesh, born in 1995, who has applied as an OBC candidate and wishes to take the exam in Vijayawada or Guntur.

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    Application

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    Prasanna Vangara
    32 views2 pages
    This document contains an application form for the JEE 2012 entrance exam. It includes personal details of the candidate such as name, date of birth, address, photo, academic details, declaration of truthfulness, and payment receipt details. The candidate is Vangara Taraka Sai Pavan from Andhra Pradesh, born in 1995, who has applied as an OBC candidate and wishes to take the exam in Vijayawada or Guntur.

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    This document contains an application form for the JEE 2012 entrance exam. It includes personal details of the candidate such as name, date of birth, address, photo, academic details, declaration of truthfulness, and payment receipt details. The candidate is Vangara Taraka Sai Pavan from Andhra Pradesh, born in 1995, who has applied as an OBC candidate and wishes to take the exam in Vijayawada or Guntur.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views2 pages

    Application

    Uploaded by

    Prasanna Vangara
    This document contains an application form for the JEE 2012 entrance exam. It includes personal details of the candidate such as name, date of birth, address, photo, academic details, declaration of truthfulness, and payment receipt details. The candidate is Vangara Taraka Sai Pavan from Andhra Pradesh, born in 1995, who has applied as an OBC candidate and wishes to take the exam in Vijayawada or Guntur.

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    Auth Code: 5d3b901dab5a67f4928898df15765554 1. Candidate Name: Vangara Taraka Sai Pavan 2. Parent/Guardian Name: Vangara Venkatadri 3.

    Date of Birth: 14-05-1995 6. Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: V.Taraka Sai Pavan,S/O V.Venkatadri D.No8-84a,Rajiv Center Mangalagiri Guntur District, Andhra Pradesh 16. PIN Code: 522503 21. Type of Preparation: Self 23. Board of QE: State Board 25. Parents' Educational Background: Neither Graduate 27. Annual Income of Parent/Guardian: Below Rs.1,00,000 22. Place of 10th Class Schooling: Town 24. Mother Tongue: Telugu 26. Occupation of Parent/Guardian: Other 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 17. Email ID: saipavanvangara@gmail.com 18. Mobile No: 09133349923 19. Landline No: 08645234288 20. PIN Code of Permanent Residence: 522503 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: OBC (NCL) 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Vijayawada (606) II. Guntur (601)

    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: .............................................................................. Fold Here Candidate Name: Vangara Taraka Sai Pavan (Signature of the Candidate)

    Candidate Signature (Sign within the box only)

    (Countersigned by Parent/Guardian) Fold Here

    STATE BANK OF INDIA


    ( TO BE FILLED IN BY BANK)

    JEE COPY

    Address: V.Taraka Sai Pavan,S/O V.Venkatadri D.No8-84a,Rajiv Center Mangalagiri Guntur District, Andhra Pradesh PIN Code: 522503 Mobile No: 09133349923 Total Payable in Figures (Including Bank Charges): Rs. 1625.00 Total Payable in Words (Including Bank Charges) Rupees:

    CBS Screen No: 8888 Fee Type: 000017 Application Form No: C26104615 Date of Birth: 14-05-1995

    Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)

    One Thousand Six Hundred and Twenty Five Only

    Date of Deposit: (Signature of the Candidate)

    ........./.........../ 2011

    (Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT MADRAS TO COMPLETE YOUR APPLICATION

    Candidate Name: Vangara Taraka Sai Pavan

    STATE BANK OF INDIA


    ( TO BE FILLED IN BY BANK) ( CASH CAN BE TENDERED AT ANY SBI BRANCH. )

    BANK's COPY

    CBS Screen No: 8888 Address: V.Taraka Sai Pavan,S/O V.Venkatadri D.No8-84a,Rajiv Center Mangalagiri Guntur District, Andhra Pradesh PIN Code: 522503 Mobile No: 09133349923 Total Payable in Figures (Including Bank Charges): Rs.1625.00 Total Payable in Words (Including Bank Charges) Rupees: Tran. No / Journal No: Branch Seal (Within the box only) Branch Code: Fee Type: 000017 Application Form No: C26104615 Date of Birth: 14-05-1995

    One Thousand Six Hundred and Twenty Five Only


    Date of Deposit:

    ........./.........../ 2011
    (Authorised Signatory)

    (Signature of the Candidate)

    * Challan can be deposited minimum one day after the generation of challan.

    JEE COPY

    IIT-JEE 2012

    INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012

    Application Form No.

    C26104615

    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

    606

    601

    APPLICATION FORM NO :

    C26104615
    To

    From Name :
    Vangara Taraka Sai Pavan

    The Chairman Joint Entrance Examination 2012

    Address :

    V.Taraka Sai Pavan,S/O V.Venkatadri D.No8-84a,Rajiv Center Mangalagiri Guntur District, Andhra Pradesh

    Indian Institute of Technology Madras Madras PIN Code - 600036

    PIN Code : Landline : Email :

    522503 08645234288

    Mobile :

    09133349923

    saipavanvangara@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.

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