Dispatched by____________________ Centre (for office use only)

ENROLMENT FORM Correspondence Programs

(Ple ase fill all t he de t ails in Block L e t t e rs )
Name & CODE of Program Enrolling for :
(For l i st of Programs & CODE s ee page no. 4) Please Affix Your
Recent Passport Size
Preference of Test Centre City Colour Photograph
for CBT AITS (JEE Main & Advanced) / Jr. AITS :
(For l i s t of Tes t Centres Ci ty s ee pa ge no. 3)

Name of the Student :

Father’s/Guardian’s Name :

Nationality : Gender: Male Female

Mother’s Name :

Student’s Aadhaar Card No. : Date of Birth: D D M M Y Y Y Y

Correspondence Address :

Pin :

Ph. (Res.) with STD Code : Mobile No. :

(Please mention your mobile no. to receive Notifications)
Permanent Address :

Pin :

Ph. (Res.) with STD Code : Mobile No. :

School affiliated to : CBSE ICSE Other (Please Specify) _____________________________

Class : IX X XI XII XII (Pass)

Science+Math/PCM (%) : VIII . % IX . % X Board . % XII Board . . %

Marks (if in Grades) : X Board- Science Maths XII Board- P C M

Scholastic Achievements (NTSE/KVPY/Olympiads/Any Other):______________________________________________________

_________________________________________________________________________________________________________

E-mail ID of the Student :

(in Block Letters)

FOR OFFICE USE ONLY

Enrolment No. :
National Admission Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 46 104 000
All India Toll Free No. 1800 11 4242, E-mail: sales.ncrp@fiitjee.com, query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com
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Nearest Relative’s/Guardian’s Address (to be contacted in case the student is not available at the above mentioned address):

Pin :

Ph. (Res.) with STD Code : Mobile No. :

Name of the School :

(Studying or Passed)

Name of the Principal :

School Address :

Pin :

Phone No.: Mobile No.:

Details of your Parents:

Particulars Father Mother

Name

Qualification

Occupation

Designation

Company Name

Company / Office Address

Company / Office Tel. No.

Mobile No.

E-mail (in Block Letters)

Annual Income

National Admission Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 46 104 000
All India Toll Free No. 1800 11 4242, E-mail: sales.ncrp@fiitjee.com, query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com
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 For JEE Year Program Program
Students CODE
Test Centres City for Computer Based All India Test Series for JEE (Main & Advanced) / Jr. AITS (only one centre can be opted):
of Class
Delhi NCR: Delhi (South), Delhi (North West), Delhi (Dwarka), Delhi (East), Faridabad, Gurgaon, Noida, Ghaziabad Andhra Pradesh:
Vijayawada, Visakhapatnam Assam: Guwahati Bihar: Bhagalpur, Darbhanga, Gaya, Muzaffarpur, Patna Chandigarh, Chhattisgarh:
Bhilai, Raipur Gujarat: Ahmedabad, Vadodara Haryana: Hisar, Karnal, Rohtak, Sonepat Jammu & Kashmir: Jammu Jharkhand:
Bokaro, Dhanbad, Jamshedpur, Ranchi, Karnataka: Bangalore, Mysore Kerala: Kochi, Thrissur, Madhya Pradesh: Bhopal, Gwalior,
Indore, Jabalpur Maharashtra: Aurangabad, Mumbai (Andheri), Mumbai (Chembur), Mumbai (Kandivali), Mumbai
(Thane),Mumbai (Navi Mumbai), Nagpur, Nashik, Pune Odisha: Bhubaneswar, Rourkela Punjab: Amritsar, Bathinda, Ludhiana
Rajasthan: Jaipur, Jodhpur, Kota, Udaipur Tamilnadu: Chennai, Coimbatore Telangana: Hyderabad Tripura: Agartala Uttar
Pradesh: Agra, Allahabad, Bareilly, Gorakhpur, Jhansi, Kanpur, Lucknow, Meerut, Shaktinagar NTPC, Varanasi Uttarakhand:
Dehradun, Haldwani, Roorkee West Bengal: Durgapur, Kharagpur, Kolkata, Siliguri.

Course Fee payment details:

Demand Draft No. Drawn on Bank (Only Nationalized Banks) Dated Amount

Check List (Please tick in the box):

1. Photocopy of 
a) X / XII Boa rd Ma rksheet*
For Ra nkers Study Ma terial a nd Computer Based All India Test Series
b) IX Cl a ss Final Ma rksheet
For Juni or Rankers Study Ma terial – (1 Yr), Al l India Open Test Series Target- NTSE
c) VIII Cl ass Final Marksheet
For Juni or Rankers Study Ma terial – (2 Yrs )
2. 4 Pa s sport Size Colour Recent Photographs 
3. Dema nd Drafts for Course Fee a s applicable 

* In case of claim for scholarship, marksheet / certificate of Scholastic Achievement is to be attested by the past / present School Principal or Gazetted Officer.
Note 1: Fee of any program is not refundable at any stage.
Note 2: All Demand Drafts should be payable at Delhi and to be made in favour of as below.
(i) MEGACOSM COGNITIONS PVT LTD for Study Material Fee.
(ii) FIITJEE LTD for Test Series Fee.
(iii) EDFORA INFOTECH PVT LTD for myPAT Online Test Series Fee.
Note 3: Please write your name at the back of your Photograph and your name & address at the back of the Demand Draft.
Note 4: Photocopy of this form can also be used.

I, ____________________________________________hereby declare that In the event of myself getting Rank in JEE Main or JEE Advanced, I will
have no objection in FIITJEE publishing my All India Rank of JEE Main or All India Rank of JEE Advanced in News Paper or in any digital platform.

Pl a ce: ______________ (Si gna ture of the Student) (Si gna ture of Pa rent / Gua rdi a n)

Da te: ______________ Na me _______________________________________________

Rel a ti ons hi p wi th the Student____________________________

Mobi l e. No. of Pa rent / Gua rdi a n _________________________

National Admission Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 46 104 000
All India Toll Free No. 1800 11 4242, E-mail: sales.ncrp@fiitjee.com, query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com
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 Ra nkers Study Ma terial (One Year Version) + Computer Based Al l India Test Series & Concept
XII/XII Pa ss 2019 1290
Strengthening Cl asssroom Program + myPAT online Test Series
Ra nkers Study Ma terial (One Year Version) + Computer Based Al l India Test Series & Concept
XII/XII Pa ss 2019 1297
Strengthening Cl asssroom Program

XII/XII Pa ss 2019 Ra nkers Study Ma terial (One Year Version) + myPAT Onl ine Test Series 1299

Computer Based All India Test Series & Concept Strengthening Cl asssroom Program + myPAT onl ine
XII/XII Pa ss 2019 1291
Tes t Series

XII/XII Pa ss 2019 Computer Based All India Test Series & Concept Strengthening Cl asssroom Program 1399

XII/XII Pa ss 2019 Achi evers Study Ma terial (One Year Version) + Computer Based All India Test Series for JEE MAIN 1268

XII/XII Pa ss 2019 Computer Based All India Test Series for JEE Ma in (January) 1280

XII/XII Pa ss 2019 Computer Based All India Test Series for JEE Ma in (April) 1295

XII/XII Pa ss 2019 Gra nd Ma sters Pa ckage 1294

Ra nkers Study Ma terial (Two Year Version) + Computer Based All India Integrated Test Series &
XI 2020 1191
Concept Strengthening Cl asssroom Program + myPAT Onl ine Test Series
Ra nkers Study Ma terial (Two Year Version) + Computer Based All India Integrated Test Series &
XI 2020 1195
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XI 2020 Ra nkers Study Ma terial (Two Year Version) + myPAT Onl ine Test Series 1198

Computer Based All India Integrated Test Series & Concept Strengthening Classsroom Program +
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myPAT Onl i ne Test Series

XI 2020 Computer Based All India Integrated Test Series & Concept Strengthening Classsroom Program 1197

Achi evers Study Ma terial (Two Year Version) + Computer Based All India Integrated Test Series for
XI 2020 1190
JEE MAIN

Juni or Rankers Study Ma terial (1 Yr) + Computer Based Junior Al l India Test Series + myPAT Onl ine
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Tes t Series

X 2021 Juni or Rankers Study Ma terial (1 Yr) + Computer Based Junior Al l India Test Series 1095

X 2021 Juni or Rankers Study Ma terial (1 Yr) + myPAT Onl i ne Test Series 1098

X 2021 Juni or Rankers Study Ma terial (1 Yr) 1094

X 2021 Al l India Open Test Series- Ta rget NTSE 1091

Juni or Rankers Study Ma terial (2 Yr) + Computer Based Junior Al l India Test Series + myPAT Onl ine
IX 2022 9091
Tes t Series

IX 2022 Juni or Rankers Study Ma terial (2 Yr) + Computer Based Junior All India Test Series 9094

IX 2022 Juni or Rankers Study Ma terial (2 Yr) + myPAT onl ine Test Series 9097

IX 2022 Juni or Rankers Study Ma terial (2 Yr) 9093

08092019

National Admission Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 46 104 000
All India Toll Free No. 1800 11 4242, E-mail: sales.ncrp@fiitjee.com, query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com
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