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Date of Birth: 24-03-1994 6. Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: House No.9-1-33/27 Prashanth Nagar Lunger House Hyderabad 16. PIN Code: 500008 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: City 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: Male 7. Year of Passing 10th Class: 2010 10. Question Paper Language: English 13. Entitled for DS Seat: No 5. Category: GE 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Hyderabad (602) II. Warangal (607)
17. Email ID: kumar.himanshu45@gmail.com 18. Mobile No: 08790070600 19. Landline No: 09652041484 20. PIN Code of Permanent Residence: 460449 PASTE RECENT COLOR PHOTOGRAPH HERE
Place : ...................... Date : ........................ Name of Parent/Guardian: .............................................................................. Fold Here Candidate Name: Himanshu Kumar Yadav (Signature of the Candidate)
JEE COPY
Address: House No.9-1-33/27 Prashanth Nagar Lunger House Hyderabad PIN Code: 500008 Mobile No: 08790070600 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: C26102479 Date of Birth: 24-03-1994
Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)
........./.........../ 2011
(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT MADRAS TO COMPLETE YOUR APPLICATION
BANK's COPY
CBS Screen No: 8888 Address: House No.9-1-33/27 Prashanth Nagar Lunger House Hyderabad PIN Code: 500008 Mobile No: 08790070600 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: C26102479 Date of Birth: 24-03-1994
........./.........../ 2011
(Authorised Signatory)
* Challan can be deposited minimum one day after the generation of challan.
JEE COPY
IIT-JEE 2012
C26102479
IIT-JEE 2012
Indian Institutes of Technology
Choice - II
602
607
APPLICATION FORM NO :
C26102479
To
From Name :
Himanshu Kumar Yadav
Address :
500008 09652041484
Mobile :
08790070600
kumar.himanshu45@gmail.com
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.