Roll No. Receipt No. Date. Remarks. Affix Passport Size Photograph here I wish to enrol in your GATE course. I herewith remit Rs. in favour of Elite Academy, Mumbai in the following way. 1. Name in full : Mr. / Mrs. / Miss. (In Block Letters) 2. Parent's / Guardian's Name : Mr. / Mrs. 3. Address : PIN 4. Contact Telephone - Res No: Cell No : Office No : 5. Date of Birth 6. Parent's/Guardian's Profession : 7. Name and full postal address to which course material is to be despatched. (In Block Letters) PIN 8. Educational Qualifications : Subject/Branch 9. E-Mail : 10. College in which you are studying now/last attended. 11. Name of Employer 84, Janmabhoomi Marg, 2nd Floor, Fort, Mumbai - 400001. Tel : 022- 66331313, 022 - 22837771 ELITE - GATE 2015 BANK DETAILS :(For Online Payment only ) Account Name : ELITE ACADEMY Account No. : 67092058762 IFSC Code for NEFT/RTGS : SBTR0000001 Bank Name : State Bank of Travancore, Mumbai Main Branch, Mumbai - 400023. PAYMENT DETAILS : M.O./Chq/DD No. : M.O./Chq/DD Date : Online Transaction ID : Bank Name : Bank Branch : CASH M.O. DD/Chq Online Bank transfer } Note : 1. At par Cheques / Cheques or DD drawn on any Bank, payable at Mumbai in favour of Elite Academy will be accepted. 2. In case of online transfer / cash deposit for online transfer at any bank branches having core banking facility, kindly send your Transaction Record printout. Bank charges are to be paid by the student. P.T.O. 12.I wish to join for the following subject/subjects in ELITE-GATE. ( Mark the appropriate box about choice of your subject) I hereby declare that the above details are true to the best of my knowledge and belief and that I have read the prospectus thoroughly and agree to abide by the rules and regulations therein. Place : Date : P. S. 1. Payment in cash will be accepted only across the counter. 2. Subject to Mumbai J urisdiction. 1. Biotechnology 2. Chemical Engineering 3. Civil Engineering 4. Computer Science & Information Tech. 5. Electrical Engineering 6. Electronics & Communication Engg. 7. Instrumentation Engineering 8. Mechanical Engineering 9. Metallurgical Engineering Signature of the Student *Strike out whichever is not applicable. 10. Production & Industrial Engg. 11. Chemistry 12. Mathematics 13 Physics 14. XE/XL* (subjects) 1. 2. 3. 4. 5. Course with QB Only Course with Only QB with & Test Series & GA GA & Test Series Test Series & GA ( MARK THE APPROPRIATE BOX) (Specify the name of the Newspaper) (Specify the name of the Newspaper) (Specify the name of the Newspaper) (Specify the name of the Newspaper) (Specify the name of the Newspaper) NOTE : I came to know about Elite Academy from : Newspaper Magazine Internet Other Sources (Specify the name of the Magazine) (Specify the Website) (Specify the Details)