IITJ13-684

IITJ13-684

ENROLMENT FORM
TWO-YEAR ELITE POSTAL COURSE FOR
JEE 2016
The Principal,
BRILLIANT TUTORIALS PVT. LTD.
Sir,
I am/was studying in
................................................................................... (Name of the Institute) (Place)
Board : CBSE ICSE State Other
Please specify
I am studying in Std. XI
I will enter Std. XI in .. (Month/year)
I have passed Std. XI but will appear for IIT-JEE in 2016.
I have passed/am in the pre-final year of the Diploma Course offered by the State Board of Technical Education.
Have you previously enrolled in any BT Course?
Yes No
If Yes, Course ....
Enrolment No.



Please enrol me as a student of your ELITE Postal Course towards JEE 2016.
Fee: Rs. 18,200/- + Service Tax Rs. 2,250/-. Total Rs. 20,450/-.

I will take the Tests On-line. My e-mail address is:

I herewith remit, the full course fee of Rs. 20,450/-


MO/DD drawn in favour of Brilliant Tutorials Pvt. Ltd., payable at Chennai.

MO Receipt / DD No. Bank Date
Net Banking/Credit Card/Online Bank Transfer ___
(Bank routing instructions given below) Transaction Confirmation No. Date
Cash/ Credit Card at your Centre in Last 4 Digits of Card No.
(See Prospectus for list of Centres)
NEFT(Send proof along with the application form)
*I would like to receive all updates and/or promotional materials as text messages on my cell phone number given below Yes No
(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.
All matters are subject to the exclusive jurisdiction of courts in Chennai only.
Yours faithfully,

Signature of Applicant Signature of Parent/Guardian
Date: Relationship to applicant

(PLEASE PRINT IN BLOCK LETTERS)
APPLICANTS NAME (as in school records)
Date of Birth : Date Month Year . Sex: Male Female


Our course material is in the English Medium only Fees 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.

Application form should be sent to: 12, Masilamani Street, T. Nagar, Chennai 600 017.
REMEMBER TO SEND TWO ADDITIONAL SIGNED PHOTOGRAPHS (preferably colour) WITH THIS FORM
Please keep a copy of this application for your records

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)

BANK ROUTING DETAILS
Pay to: BRILLIANT TUTORIALS PVT LTD.
Account No. 0345002100269947
Bank, Branch: PUNJAB NATIONAL BANK LTD,
10, RAJA STREET, CHENNAI, T.NAGAR 600 017.
IFSC Code For NEFT: PUNB0034500
Note: Payment by NEFT only. Bank charges to be paid by student.
Name of Parent / Guardian :
Permanent Home Address:
Telephone Number: STD Code: Cell Phone: *
PP
Fax: E-Mail: * PIN CODE:
Name of Parent / Guardian and Address
to which all Correspondence and study
material should be dispatched:
Telephone Number: STD Code: Cell Phone: *
PP
Fax: E-Mail: * PIN CODE:











Visa Master Card
ELITE 2016
REFERENCE NUMBER:
B T

.....
12, Masilamani Street, T. Nagar, Chennai 600 017.
For Office Use only
Student No:

P 2 E C 1 6