www.BansalTestPrep.

com

Student Enrollment Application Form

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Helpline Number : +91-9571042039

Email : admin@bansaltestprep.com

Candidate Details
*JEE Main Application Form No. (if applicable) ___________________________________________
*BITSAT Application Form No. (if applicable)

___________________________________________

*NEET UG Application Form No. (if applicable) ___________________________________________

Name

Rahul Kumar Kumar

Gender

Father's Name

Binod Prasad Jaiswal

Address

tinku medical, bank road motihari

City

Motihari

Pincode

845401

Landline

______________

NTSE Qualified

Yes

No

Date of Birth

1996-12-05

State

Bihar

Mobile

9571689053

KVPY Qualified

Yes

Courses Purchased

No

Fee

All India Online Test Series for JEE (Advanced and Main) 2014

Rs 2600

Transaction and Registration Details :

Username

rahulkr693@gmail.com

Order ID

19101

Transaction Date/Time

2013-10-05 12:16:43

Payment Mode

cash

Online Txn/DD No.

_________________

Amount

Rs 1950

Scholarship Code Availed

BSES07

Declaration
I hereby solemnly affirm that I agree by the rules and regulation of Bansal Classes Pvt Ltd/www.bansaltestprep.com
I hereby solemnly affirm that the above details furnished by me above are true and correct. I abide by the rules and regulation governing
www.bansaltestprep.com as contained by Bansal Classes Pvt Ltd.
I hereby accept that after joining www.bansaltestprep.com by paying necessary fee, if I withdraw from the course at any stage, no refund will be made
to me.
If I get selected in any competitive examination Bansal Classes Pvt. Ltd. can publish and display my name and photograph on its website, promotional
material ( all mediums of promotions i.e. newspaper , online , on air etc )
I hereby accept that if I don't submit the application form with 20 days after buying course, institute reserves the right to take necessary actions.
I hereby agree to receive every information regarding www.bansaltestprep.com via phone call , sms , email or any other mode of communication.
All disputes are subject to Kota ( Rajasthan ) Jurisdiction Only.
* Please attach a photocopy of the Application Form(s) for which you have filled Application Number(s) along-with this form. This will help us
serve you better.

Signature with date (Applicant)

Signature with date (Father/Guardian)

Send the complete application form along with all required enclosures to the following address :
The Administrator (BansalTestPrep.com)
Bansal Classes Pvt. Ltd.
Gaurav Tower', A-10 Road No. 1, IPIA
Kota - 324005
Rajasthan, India