12, Masilamani Street, T. Nagar, Chennai 600 017.

Student No:

For Office Use only E G

3 Affix Passport Size Photo here 4.5 4.5 cms Enclose two signed photographs with this Form (Enrolment Forms will not be accepted without three photographs)

ENROLMENT FORM SUPPORT PROGRAMME FOR

GATE, 2013
The Principal, BRILLIANT TUTORIALS PVT. LTD. Sir,
PLEASE ENSURE THAT THIS IS THE COURSE YOU WISH TO APPLY AND ENROL FOR. COMPLETE AND SIGN BOTH SIDES OF THIS FORM.

I have passed/will pass in (Name of Course) (Month/year) from DO NOT REMOVE THIS LABEL OR WRITE IN THIS SPACE (Name of Institution and Place) Discipline (Major Subject) Have you previously enrolled in any BT Course? Yes No If Yes, Course .,,... Enrolment No. FOR OFFICE USE ONLY Please enrol me as a student of your Support Programme for GATE 2013 Postal Course with Online Test Series Postal Course only Online Test Series only I herewith remit the full course fee of Rs. /- by: MO/DD drawn in favour of Brilliant Tutorials Pvt. Ltd., payable at Chennai. MO Receipt / DD No. Net Banking/Credit Card/Online Bank Transfer
(Bank routing instructions given below)

Bank Transaction Confirmation No.

Date
Visa Master Card

Date

Cash/ Credit Card at your Centre in

Credit Card Authorization Code Last 4 Digits of Card No. Yes No

*I would like to receive all updates and/or promotional materials as text messages on my cell phone number given above

(Please the appropriate boxes) I have read and shall abide by the rules and regulations for this Course given in the Online / Hardcopy Prospectus. Fees once paid will not be refunded or adjusted under any circumstances. BANK ROUTING DETAILS All matters are subject to the exclusive jurisdiction of courts in Chennai only. Yours faithfully,
Pay to: BRILLIANT TUTORIALS PVT LTD. Account No. 014010200034654 Bank, Branch: AXIS BANK LTD, T.NAGAR BRANCH, CHENNAI 600 017. IFSC Code For NEFT: UTIB0000014 Note: Payment by NEFT only. Bank charges to be paid by student.

Signature of Applicant Date:

(PLEASE PRINT IN BLOCK LETTERS)

Applicants Name (as in school records)..............: Date of Birth : Date Month Year Permanent Home Address:

Sex:

Male

Female

Telephone: Own Fax:

STD Code: PP

Number:

Cell Phone: *

E-Mail: *

PIN CODE:

Name and Address to which all Correspondence and study material should be despatched:

Telephone: Own Fax:

STD Code: PP

Number: E-Mail: *

Cell Phone: *

PIN CODE:

Our course material is in the English Medium only Fee once paid will not be refunded or adjusted under any circumstances. No instalment facility. Enrolment will not be accepted without the photograph/s. PIN CODE, AN ABSOLUTE MUST. Your application for admission will not be accepted unless your address is complete with Pin Code. *Denotes mandatory fields. Brilliant Tutorials reserves the right to use the photographs and/ or testimonials from the student in promotional / publicity material. REMEMBER TO SEND TWO ADDITIONAL SIGNED COLOR PHOTOGRAPHS WITH THIS FORM. Please keep a copy of this enrolment form for your records

GATE 2013
I. ENGINEERING SUBJECTS: STUDY MATERIAL ONLY
INSTRUMENTATION ENGINEERING (IN) PHYSICS (PH) Rs. 19,348/- (Fee: Rs.17,220/- + Service Tax Rs. 2128/-) Rs. 13,267/- each (Fee: Rs. 11,808/- + Service Tax Rs. 1459/-)

STUDY MATERIAL WITH (OPTIONAL) TEST SERIES Engineering Subjects (Choose one) Mechanical Engineering (ME) Electrical Engineering (EE) Electronics and Communication Engineering (EC) Fees: Study Material only Study Material + TS9 Study Material + TS5 TS9 Test Series only TS5 Test Series only II. LIFE SCIENCES (XL) Please all the options you would like to take.
LIFE SCIENCES (XL) Chemistry (Compulsory) (H) CHOOSE ONE OR BOTH SUBJECTS Biochemistry (I) Microbiology (K)

Computer Science & Info. Technology (CS) Production and Industrial Engineering (PI) Biotechnology (BT)

: : : : :

Rs. 19,348/- (Fee: Rs. 17,220/- + Service Tax Rs. 2128/-) Rs. 22,746/- (Fee: Rs. 20,244/- + Service Tax Rs. 2502/-) Rs. 21,721/- (Fee: Rs. 19,332/- + Service Tax Rs. 2389/-) Rs. 3398/- (Fee: Rs. 3024/- + Service Tax Rs. 374/-) Rs. 2373/- (Fee: Rs. 2112/- + Service Tax Rs. 261/-)

Study Material only Study Material + TS9 Test Series Study Material + TS5 Test Series TS9 Test Series only TS5 Test Series only Fees: Study Material Only: a. Compulsory Subject with two Optionals b. Compulsory Subject with one Optional c. Two Optionals without Compulsory d. One Optional without Compulsory e. Compulsory Subject only Fees: Study Material with (Optional) Test Series: Chemistry (Compulsory) + TS9 Chemistry (Compulsory) + TS5 Study material + TS9 Biochemistry / Microbiology Study material + TS5 Biochemistry / Microbiology : : : : Rs. 10,611/- (Fee: Rs. 9,444/- + Service tax Rs. 1,162/-) Rs. 9,587/- (Fee: Rs. 8,532/- + Service tax Rs. 1,055/-) Rs. 8,858/- (Fee: Rs. 7,884/- + Service tax Rs. 974/-) each Rs. 7,942/- (Fee: Rs. 7,068/- + Service tax Rs. 874/-) each TS9: Rs. 3,398/TS5: Rs. 2,373/: : : : : Rs. 18,135/- (Fee: Rs. 16,140/- + Service tax Rs. 1995/-) Rs. 12,674/- (Fee: Rs. 11280/- + Service tax Rs. 1394/-) Rs. 10,921/- (Fee: Rs. 9,720/- + Service tax Rs. 1201/-) Rs. 5,461/- (Fee: Rs. 4,860/- + Service tax Rs. 601/-) Rs. 7,214/- (Fee: Rs. 6,420/- + Service tax Rs. 794/-)

Add: Additional Test Series Chosen: For EACH Optional

TOTAL FEES (for XL option): Rs.

Students Signature:

/Date :