JEE- 2011

APPLICATION FORM FOR ADMISSION

INDIAN INSTITUTES OF TECHNOLOGY
Bhubaneswar, Bombay, Delhi, Gandhinagar, Guwahati, Hyderabad, Indore,
Kanpur, Kharagpur, Madras, Mandi, Patna, Rajasthan, Roorkee, Ropar
ISM Dhanbad and IT-BHU Varanasi

1. JEE-2011 Registration No. 2. a) All India Rank

b) Category Rank
3. JEE-2011 Application No. Paste your recent
4. Nationality photograph here
(I-Indian/F-Foreigner)
5. Category
[Please  wherever applicable] GE OBC(NCL) SC ST DS PD

6. Applicant’s Name ……………………………………………………………………………………………………

7. Date of birth (DD/MM/YYYY):…….…….…………….……. 8. Sex:…………………………….

9. Parent’s/Guardian’s Name………………………………………………………………………………………….

10. Permanent Address 11. Address for Communication

………………………………………………… ………………………………………………….

………………………………………………… ………………………………………………….

………………………………………………… ………………………………………………... .

Pin Code……………………………………... Pin Code……………………………………….

Mobile No…………………………………….. Email id…………………………………………

12. Academic Qualifications

Year of Percentage
Examination School/College Board/University of marks
Passing
th
10 Class

10+2 Class/
Intermediate
Any other
public examination

13. Are you colour blind or uniocular? Yes/No

14. Declaration:
I hereby declare that the particulars stated above are true to the best of my knowledge and belief. In the
event of suppression or distortion of any fact, I understand that my admission/degree acquired is liable to
cancellation. I also understand that the decision of the Joint Admission Board regarding my admission to any of
the IITs/ ISM Dhanbad/ IT-BHU Varanasi is final and I shall abide by the rules and norms of the discipline of
the Institute which I join.

Left thumb impression of the Candidate……………………………….. Signature of the Candidate

Place:…………………….
Date:……………………... Countersigned by Parent/Guardian

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