APPLICATION FORM

ALL INDIA OPEN

MATHEMATICS SCHOLARSHIP EXAMINATION

SINCE-1996

STD.

III:

IV:

V:

VI:

VII:

VIII:

IX:

Notes:
1. Fill all the information in English Capital Letters using Blue Ink only. STD:
2. Write only one letter in one box wherever provided.
3. Use a tick mark (
) wherever necessary.
Medium:
1.

Name of the Candidate:

Surname:
First name:
Father's name:

2.

Residential Address: ________________________________________________________

_________________________________________________________________________
_______________________________________________Pin Code:
E-mail:___________________________________________________________________
Telephone No.
Mobile No.

3.

Date of Birth: In figures:

(Date)
Male:

Female:

(Month)
5.

I.P.Ms

(Year)
If appeared in 2008-09.

4.

Sex:

P.R.No

6.

School's Name and Address:__________________________________________________

(See mark sheet)

_______________________________________________Pin Code:
School Telephone No.
School E-mail:_____________________________________________________________
7.

Medium of Examination:

English

8.

Details of Payment: Cheque

Marathi
Draft:

Amount: 200/- (Rs.Two Hundred Only)

Cheque/Draft no. ___________________ Name of the Bank: ________________________

( Payments only by Cheque/ D.D.for Pune & Mumbai.out station students pay by D.D.only,
Drawn on Institute for Promotion of Mathematics. Last date of submission of application form 30 Nov.)
(Write the students name,schools name, standard and Phone No behind the Cheque/ D.D.)
9.
10.

I have read all the rules and regulations in the brochure and will abide by them.
Please keep a xerox copy of the Application form and the Brochure for your record.
Signature of the Candidate: ___________________________________________________
Date:_________________Signature of the Parent/Guardian: ________________________

Seal /Stamp of the School

Signature of the Principal

Institute for Promotion of Mathematics 46/C,Aundh Road, 103-Prerna Building, Opp. HDFC Bank.
Khadki, Pune - 411020.Phone No: (020) 2581 8606, 2581 0540 Visit vs at www.ipmindia.in