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Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: 35/114c Nagla Bhaawani Singh Devori Road Agra 16. PIN Code: 282001 21. Type of Preparation: Self 23. Board of QE: CBSE 25. Parents' Educational Background: Only One Graduate 27. Annual Income of Parent/Guardian: Rs.1,00,000 - 4,50,000 22. Place of 10th Class Schooling: Town 24. Mother Tongue: Hindi 26. Occupation of Parent/Guardian: Defense Service 3.5 cm x 4.5 cm with the face covering about 75% of the photo 4. Gender: Female 7. Year of Passing 10th Class: 2010 10. Question Paper Language: English 13. Entitled for DS Seat: No 5. Category: SC 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Delhi (South) (204) II. Delhi (North) (203)
17. Email ID: OMPRIYA.GOEL@GMAIL.COM 18. Mobile No: 09897137489 19. Landline No: 05622411855 20. PIN Code of Permanent Residence: 282001 PASTE RECENT COLOR PHOTOGRAPH HERE
Place : ...................... Date : ........................ Name of Parent/Guardian: .............................................................................. Cut Here (Signature of the Candidate)
SEND THE UPPER PART TO JEE OFFICE IIT DELHI TO COMPLETE YOUR APPLICATION
JEE COPY
IIT-JEE 2012
C22301343
IIT-JEE 2012
Indian Institutes of Technology
Choice - II
204
203
APPLICATION FORM NO :
C22301343
To
From Name :
Ompriya
Address :
Indian Institute of Technology Delhi Hauz Khas, Delhi PIN code - 110016
282001 05622411855
Mobile :
09897137489
OMPRIYA.GOEL@GMAIL.CO M
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. 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.