ENROLMENT FORM Form No.

2021----
THE ORIGIN CHEMISTRY CLASSES -
ACEDEMIC SESSION _____________

ALL ENTRIES MUST BE FILLED IN CAPITAL LETTERS ONLY.

COURSE APPLIED FOR FOR OFFICE USE
PASTE YOUR
XIth APPEARING ROLL NO.
XIIth APPEARING LATEST PASSPORT
XIIth PASSOUT SIZE PHOTOGRAPH
HERE
Name of Batch
IITJEE NEET

SIGN. HERE

DATE----------------------------------------
PERSONAL INFORMATION
1.Name

2.Father’s
Name

3.Mother’s
Name
4.Date of Birth: 5. GENDER: MALE FEMALE

6.Father’s / Guardian Occupation : Business

Service
8.Contact No.
Mobile No. of Student _______________________WHATSAPP No.____________________ Mobile No. Of Parent____________________
9.Past Academic Performance:
Examination School Board Year of Passing Max. Marks
10th
11th
12th

10.Fee Category : Once Payment Installment Date of 2nd Installment _______

(after One Month)
11.Mode of payment : By Cash ONLINE (UPI/PHONPE/NEFT/RTGS -----------------------)

12. Contact Details : Present Address :

Permanent address

13.Rules &Regulations :
01. Mention your correct Name, Address and Contact No. (Students and Father) while filling the Enrolment Form.
02. Students once enrolled in any courses cannot claim for refund of fee or part of the fees. If He/She becomes disinterested
during the course due to any reason what so ever.
03. All Disputes will subjected to Bokaro Steel City Jurisdiction only.
04. I have read the terms and conditions and promise to abide by the same.
SIGNATURE OF STUDENT

U. K. SINGH SEAL
( Director) SIGNATURE OF PARENT