QU ESTIONNAIRE

Q.1

Please, encircle the motivation Level in front of the Source of

Motivation e.g. : 0 1 2 3 4 5
Note : Here 0 to 5 represent increasing level of motivation for
the particular source.

What motivated you to apply for

PRUDENT LEARNING?

S.No.

Source of Motivation

Motivation Level

S.No.

Source of Motivation

Motivation Level

1.

Authenticity & Growth in Results

0 1

2 3 4 5

8.

Personal Visit of the institute

0 1

2 3 4 5

2.

Directors Vision & Commitment

0 1

2 3 4 5

9.

Analytical Comparison with other institute(s)

0 1

2 3 4 5

3.

Faculty Team

0 1

2 3 4 5

10.

Overall Academic Environment

0 1

2 3 4 5

4.

Recommended by others

0 1

2 3 4 5

11.

No Particular Reason

0 1

2 3 4 5

5.

Raipur Factor

0 1

2 3 4 5

12.

Any other reason :........................

6.

Public Image

0 1

2 3 4 5

.........................................................

0 1

2 3 4 5

7.

Advertised/ Marketed Image

0 1

2 3 4 5

.........................................................

02. Have you applied OR Do you intend to apply to other institute for
IIT-JEE preparation ?
(i) Have you applied to other institues for IIT-JEE

Yes

No

03. If Selected OR Given a choice, what priority

would you assign to us ?
S.No.
Priority to Join PRUDENT

preparation ?
If Yes, then how many ? : 1

(ii) If not applied so far, Do you intend to apply to

1.

Always First

2.

A Close Second

3.

Distant Third

4.

Impossible Last

5.

Cant say at the moment

More than 3

Yes

No

other institutes for IIT-JEE preparation ?

If Yes, then how many ? : 1

More than 3

04. If you have used the Selection Matrix for How to Choose a
Coaching Institute developed by Prudent , please do let us
know your assessment :

05. If you think, there are some parameters whose weightage

points are either to be modified or to be excluded from the
Selection Matrix.

Parameter
Existing
Modified
Remarks
Weightage Points Awarded Points Awarded Points Awarded S.No.
Weightage Points
Weightage Points
Points
to Exponent
to Other
to Other
1
Institute-1
Institute-2
2
1. Result
20 Points
3
2. Leadership
05 Points
3. Faculty
20 Points
*Put Zero in the box of modified weightage points if a parameter is to be excluded.
4. Teaching Methodology 15 Points
Q6. If you think, there are some parameters which are not presently included but
5. Academic Environment 10 Points
should be incorporated in the Selection Matrix :
6. Public Image
05 Points
7. Admin. & Mgmt.
05 Points
S.No.
Parameter
Proposed
Remarks
8. Infra. & Facilities
05 Points
Weightage Points
9. Cost of Study
10 Points
1
10. Overall System
05 Points
2
GrandTOTAL
100
3
S . Parameter
No.

07. In case of emergency, who do you recommend to be contacted on your behalf ?

Name of the person :
Tel. No.: 0

Moblie
No.

STD Code

( Telephone No.)

E-mail :

Relationship

08. If your have any guardian in Raipur, please provide here his/her details :
Name of the person :
Tel. No.: 0
STD Code
E-mail :

Moblie
No.

( Telephone No.)

Relationship

22.

Postal/Mailing Address (Do not write your Fathers Name)

City/Town/P.O.:
District:
State:
Country:

Pin Code:

Tel. No.: 0

Mobile No. 0

STD Code

( Telephone No.)

E-mail :

23. Applicants Permanent Residential Address (Write only if it is different from Postal/Mailing Address):

City/Town/P.O.:
District:
State:
Country:

Pin Code:

Tel. No.: 0

STD Code

Mobile
No.

Moblie
No.

( Telephone No.)

E-mail :

24. Tel./Mobile No./E-mail of two close relatives (other than parents)

Tel. No.: 0

Relative 1 :

STD Code

( Telephone No.)

E-mail :

Relationship

Tel. No.: 0

Moblie
No.

Relative 2 :

STD Code

( Telephone No.)

E-mail :

Relationship

25. Personal Information :

Height :

Feet

Weight :
Shirt/T-Shirt Size :

OR Centimeter

Inches
Blood
Group

Kilogram
S

Eye Sight :

Normal

Weak

Yes

No

Do you wear spectacles :

XL

Right Eye Left Eye

XXL
Vision

Waist :

26

28

30

32

34

36

38

40

Ref.

Distance
Near

DECLARA TION
I hereby certify that the information given in the admission form(as well as in all other relevant documents) is complete and accurate to the best of my knowledge and belief. I understand
and agree that misrepresentation or omission of facts will justify the denial/cancellation of my admission, or expulsion from the institute at any stage of the academic session. I have
read and do hereby provide consent to the Terms & Conditions and all relevant information as mentioned. Further, if admitted, I Promise to abide by the rules & regulations and
norms of discipline of the institute as long as I remain a registered student of PRUDENT LEARNING.
I also declare that being an enrolled student of PRUDENT LEARNING , I will be responsible to it in terms of providing relevant details of all the competitive examinations (in the
form of true photocopies of the application form of the relevant examination) that I will be appearing in the future by virtue of coaching & academic support form the institute. If
I succeed in any of these competitive examinations, the institute will have all the rights of using my result and photograph in any form for its growth strategies and development plans.
In such a case Ill never ever have any objection or protest for this.
Signatute of one of the Parents/Guardian
Date

Place

If Signed by Guardian, write his/her Name:

Signatute of the Student

Date
Relationship :

Place
Contact No. :

12. Details of Performance :

Class
Year of
Name of School
Passing Out
IX

City

State

Board

% Marks
(Aggreagate)

%Marks in
Sc+M/PCM

Remarks

X
XII
13. Medium of studies so far :
S.No.

Standard

English()

1.

Till VIII

2.

During IX & X

3.
After X
14. Medium of studies to be opted

Hindi ()

English

Other ()

Specify it, if other is Chosen

Hindi

15. Past Performance in Competitive Examinations (fill only if relevant) :

S.

Examination

Year

Level Cleared

Marks Obtained

I/II/Final

Max. Marks

No.
1.

STSE/NTSE

2.

Science Olympiads

3.

State PET (SLEEE)

4.

AIEEE

5.

IIT- JEE

% Marks

Rank

Remarks

AIR/ASR

6.
16. Information about coaching for IIT-JEE in the past (fill only if relavant)
Class

During IX/X

Did you take Coaching earlier

Yes

Mode of Coaching

Classroom

During XI

No.

Yes

Correspondence

Classroom

During XII

No.

Yes

Correspondence

Classroom

No.
Correspondence

Name of the Coaching Institute

City/Place of Coaching
17. Have you ever studied in PRUDENT ? Yes
If yes, give details :
No

18. Have your real brother (s)/sister(s) ever studied in PRUDENT ?

If yes, give details :

S.No. Academic Session Course Name Final

Batch
1.

S.
No.

2.

2.

Name

Yes
No

Roll No. Academic Relationship Course Final Selected

Session (Brother/
Name
Batch in IIT-JEE
Sister)
Yes No

1.

Yes

No

19. Parents/Guardians Occupation :

S.No.

Occupation

1.

Agriculture

S.No.

Occupation

4.

S.No.

Occupation

Defence Service

7.

2.

Artist

5.

Doctor

8.

3.

Business

6.

Engineer

9.

S.No.

Occupation

Law Practice

10.

Teaching/Research

Public/Govt.
Service

11.

Self-employed

Private Service

12.

Other

20. Parents/Guardians Educational Background :

S.No.
1.

Education
Post Graduate

Father

Mother

( )

( )

S.No.
4.

& above

21. Parents/Guardians Annual Household Income

Education

Father

Mother

( )

( )

S.No. Annual Income S.No. Annual Income

Secondary

1.

< Rs. 50,000/-

4.

Rs. 1.5 Lac-3Lac

passed

2.

Rs. 50,000- 1 Lac

5.

Rs. 3 Lac-5Lac

2.

Graduate

5.

Below Secondary

3.

Rs. 1 Lac-1.5 Lac

6.

> Rs. 5 Lac

3.

10+2 Passed

6.

No Formal Edu.

PRUDENT LEARNING
Side Effect Includes - Enhanced Performance

ADMISSION FORM
Academic Session : 2016-2017

1. Application Form No.

Important Instructions :

3.

Use only CAPITAL LETTERS of English language to complete the admission Form.
The Application form consists of Four Pages No. 1 to 3 are having mandatory fields.
Page No. 4 is optional and contains a QUESTIONNAIRE. We request the student/parents to
give it a look and provide required information with full honesty and sincerity.
Please, read very carefully before filling up the admission form.
Use only Black/Blue Ball Point/Gel Pen to complete the admission Form.
Tick( ) in the relevant box wherever applicable.
An Application Form carrying incomplete information may be rejected by the Institute.

2. Paste your recently

taken passport size
Colour Photograph
(3.5cm x 4.5cm)

Name of the Student

6.

4.

Fathers Name :

5.

Mothers Name :

6.

State of Domicile :

Date of Birth :
D M M

Y Y Y

8. Gender :
M
F
6.

Category :

GEN SC

10. Course you are applying for :

(i) YEAR-LONG CLASSROOM COACHING PROGRAMMES (YCCPs)

ST OBC DS PD

(ii) DISTANCE LEARING PROGRAMMES (DLPs)

S.No.

Target

Course Name

Code

1.

NTSE

INTENSE

1.

IIT-JEE20___

2.

IIT-JEE

INNOVATIVE

2.

IIT-JEE20___

3.

IIT-JEE

INDUCTION

3.

IIT-JEE20___

4.

IIT-JEE

IMPACT

4.

IIT-JEE20___

5.

AIPMT

IMPULSE

11.

S.No.

Target

Course Name Code

How did you come to know aboutPrudent?(In the Source Details, write Newspapers/Magazine/ Websites Name, Friend/Relative/Old Students Name & Contact No.)

S.NO.

Source

Source Details

S.NO.

Source

1.

Newspapers

5.

Old Students

2.

Magazines

6.

Internet/Website

3.

Friends/Relatives

7.

Self-explored

Any other Source. :

Source Details