ENROLMENT FORM Distance Learning Programs

(Please fill all the details in Block Letters)

Code & Name of Program Enrolling for :
(Refer page 4)
Please Affix Your
Recent Passport Size
Preference of Test Centre City : Colour Photograph
For Computer Based All India Test Series (AITS) / Junior AITS
(Refer page 3)

Name of the Student :

Father’s/Guardian’s Name :

Mother’s Name :

Nationality : Gender : Male Female

Date of Birth : D D M M Y Y Y Y

Correspondence Address :

Pin :

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

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

Pin :

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

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

Class Presently in : IX X XI XII XII (Pass)

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

Grades (if Marks not given): X Board - Science Maths XII Board - P C M

Scholastic Achievements (NTSE/KVPY/Olympiads/Any

Other):______________________________________________________

Category of Student : General Other (Please specify) ____________________________

E-mail ID of the Student :
(in Block Letters)

FOR OFFICE USE ONLY

Enrolment No. :
March 2020

Signature of EDP Dispatched by__________________________________ Centre (for office use only)

National Admissions Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 4610 4000
All India Toll Free No. 1800 11 4242, E-mail: query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com 1/4
Nearest Relative’s/Guardian’s Address (to be contacted in case the student is not available at the above mentioned address):

Pin :

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

Name of the School :

(Studying or Passed)
Name of the Principal :

School Address :

Pin :

Ph. No. (with STD Code): 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
March 2020

National Admissions Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 4610 4000
All India Toll Free No. 1800 11 4242, E-mail: query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com
2/4
Test Centres City for Computer Based All India Test Series (AITS) / Junior AITS (only one centre can be opted):
Delhi NCR: Delhi (South), Delhi (North West), Delhi (East), Faridabad, Ghaziabad, Gurgaon, Noida, 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 Kerala: Kochi, Thrissur, Madhya Pradesh: Bhopal, Gwalior, Indore,
Jabalpur Maharashtra: Aurangabad, Mumbai, Nagpur, Nashik, Pune, Wardha Odisha: Bhubaneswar, Cuttack, Rourkela Punjab:
Amritsar, Bathinda, Ludhiana Rajasthan: Jaipur, Jodhpur, Kota, 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 Dated Amount

Have you ever appeared in FIITJEE Admission Test for Classroom Program? Yes/ No
If Yes, please give your 19 Digit Reg No./ Month & Year in which you appeared in the Admission Test.

Documents to be submitted along with the Enrolment Form :

Check List (Please tick in the box)
1. Photocopy of 
X / XII Board Marksheet*
For Rankers Study Material Program / Achievers Study Material Program / Computer Based All India Test Series Program
OR Class IX Final Marksheet
For Junior Rankers Study Material (One Year Program for Class X) / All India Open Test Series Target- NTSE Program
OR Class VIII Final Marksheet
For Junior Rankers Study Material (Two Year Program for Class IX)
2. Four Passport Size Recent Colour Photographs 
3. Demand Drafts for Course Fee as applicable 
Demand Drafts should be payable at Delhi, in favor of as given below :
(i) Megacosm Cognitions Pvt. Ltd. for Books Fee.
(ii) FIITJEE Ltd. for Computer Based All India Test Series Fee.
(iii) Edfora Infotech Pvt. Ltd. for myPAT Online Test Series Fee.
* In case of claim for scholarship, marksheet / certificate of Scholastic Achievement is to be attested by the School Principal or Gazetted Officer.
Note 1: Please write your name on the back side of your Photograph and your name & mobile no. on the back side of the Demand Draft.
Note 2: Fee paid for Program is not refundable at any stage.
Note 3: Please keep a photocopy of your duly filled Enrolment Form.

You can submit your complete Enrolment Form along with all documents at the nearest FIITJEE Centre OR you can send it by Speed Post
/ Courier addressed to National Admissions Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016
In case you are submitting your Enrolment Form at a FIITJEE Centre, please also inform us at query.dispatch@fiitjee.com mentioning
(i) Name of Student (ii) Program Code & Program Name Enrolling in (iii) Fee details i.e. Demand Draft amount, Demand Draft No.
(iv) FIITJEE Centre’s complete address where you have submitted your Enrolment Form. (v) Date of submission of Enrolment Form.

I, ____________________________________________hereby declare that In the event of myself getting All India 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.
Place: ______________ (Signature of Parent / Guardian)
March 2020

Date: ______________ (Signature of the Student) Name _______________________________________________

Relationship with the Student____________________________

Mobile. No. of Parent / Guardian _________________________

National Admissions Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 4610 4000
All India Toll Free No. 1800 11 4242, E-mail: query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com 3/4
For Students Program
Program
Of Code

1290 Rankers Study Material 2020-21 (One Year Program for JEE Advanced 2021) with myPAT

1297 Rankers Study Material 2020-21 (One Year Program for JEE Advanced 2021)

Class XII / 1291 Computer Based All India Test Series 2020-21 (One Year for JEE Advanced 2021) with myPAT
XII Pass
1399 Computer Based All India Test Series 2020-21 (One Year for JEE Advanced 2021)

1268 Achievers Study Material 2020-21(One Year Program for JEE Main 2021)

1191 Rankers Study Material 2020-22 (Two Year Program for JEE Advanced 2022) with myPAT

1195 Rankers Study Material 2020-22 (Two Year Program for JEE Advanced 2022)
Class XI
1192 Computer Based All India Integrated Test Series 2020-22 (Two Year for JEE Advanced 2022) with myPAT

1197 Computer Based All India Integrated Test Series 2020-22 (Two Year for JEE Advanced 2022)

1093 Junior Rankers Study Material 2020-21 (One Year Program for Class X) with myPAT

Class X 1095 Junior Rankers Study Material 2020-21 (One Year Program for Class X)

1091 All India Open Test Series - Target NTSE 2020-21

9091 Junior Rankers Study Material 2020-22 (Two Year Program for Class IX) with myPAT
Class IX
9094 Junior Rankers Study Material 2020-22 (Two Year Program for Class IX)

1397 Computer Based All India Test Series (from Open Test) for JEE (Advanced), 2020

1398 Computer Based Mini Test Series for JEE Advanced 2020

1292 Open Test (CBT) for JEE Main 2020 (Test Date : 9th Feb 2020)
XII / XII
Pass 1293 Open Test (CBT) for JEE Advanced 2020 (Test Date : 19th April 2020)
March 2020
1296 Grand Masters Package & myPAT Online Test Series for JEE Advanced 2020

1294 Grand Masters Package for JEE Advanced 2020

National Admissions Office (NCRP), FIITJEE House, 29 - A, Kalu Sarai, Sarvapriya Vihar, New Delhi-110 016, Ph: 011 – 4610 4000
All India Toll Free No. 1800 11 4242, E-mail: query.dispatch@fiitjee.com, Website: www.fiitjee-distancelearning.com / www.fiitjee.com 4/4