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L I M I T E D

APPLICATION FORM FOR FIITJEE AWARD


Name of the Student : ____________________________________________________
FIITJEE Enrolment No. : ____________________________________________________
Program Name : ____________________________________________________
Study Centre : ____________________________________________________
Year of passing IIT-JEE/JEE (Advanced) : ____________________________________________________
All India Rank : ____________________________________________________
Name of the IIT/Engineering/Undergraduate College in which studying : ___________________________
____________________________________________________________________________________________
Semester & Year in which studying : Semester_________________________ Year _______________
Amount of award admissible per year : ____________________________________________________
The Year for which award is being claimed : II / III / IV

Dated: ______________ (Signature of the Student)

Name : ________________________________

Permanent Residential Address (in Capital letters): Correspondence Address (in Capital Letters):
_________________________________________ _______________________________________
_________________________________________ _______________________________________
Phone (with STD code): ______________________ Phone (with STD code): ____________________
Mobile No.: _______________________________ Mobile No.: _____________________________
E-mail ID: _________________________________ E-mail ID: _______________________________

Attestation by IIT/Engineering/Undergraduate College Authorities:


Certified that Mr. __________________________________ S/o _____________________________________
was studying in ___________ year of IIT/Engineering/Undergraduate College and has passed the same. He has
good moral character.

Signature of Authorised Person


Date : _________________ (with seal of the Institute)

FOR OFFICE USE:


Passed for payment of Rs.___________________
(Rupees_______________________________________________________) (Authorised Signatory)

Paid vide Cheque No. _______________ dated _____________ for Rs. ______________ drawn on
______________________________________________________.

(Sr. Accountant) (Dy. Manager - Accounts)

FIITJEE House, 29-A, Kalu Sarai, Sarvapriya Vihar, New Delhi -110016
Ph.: 011-49283471/73/74/75 Fax: 011-26513942 e-mail: info@fiitjee.com
Documents required to be submitted by the Students at their FIITJEE Study Centre (Academic Operations
Department):

i. A written letter addressed to Centre Head of your FIITJEE Study Centre & duly signed by you (student) to
claim their FIITJEE scholarship applicable. This letter must contain name of their FIITJEE Study Centre,
their Enrolment No., their All India Rank in JEE Advanced & their JEE Year.

ii. Filled up Application Form duly attested by concerned IIT or Engineering / Undergraduate College.

iii. Copy of students Identity Card of IIT or Engineering / Undergraduate College where student is studying in.

iv. Semester/ Year result copy duly attested by IIT or Engineering / Undergraduate College where student is
studying in.

FIITJEE House, 29-A, Kalu Sarai, Sarvapriya Vihar, New Delhi -110016
Ph.: 011-49283471/73/74/75 Fax: 011-26513942 e-mail: info@fiitjee.com

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