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Kanipla, Kurukshetra, Haryana India-136131

Regd. Under NCT & Ministry of Labour Govt. of India

New Student Registration Form

(All the information required to fill in capital letters only)

For Office Use Only

Fee payment details (details of DD/Pay Order)

1. Rec. No. ____________Amount__________Date_________Bank__________

Passport
Size
2. Rec. No___________Amount__________Date_________Bank_____________
Photo

Signature
E-Max Institute of Information Technology E-Max Institute

Regd No_______________ Study Center

Admission details

Name of Student : ___________________________________________________

(in CAPITAL LETTERS)

Father Name : ______________________________________________________

Mother Name : ______________________________________________________
Admission Date :_____________
Admission to Trade : ____________________________________________________.
Study Center Name : ______________________________________Batch: 20____-20____.
Date of Birth : ____________________ Place of Birth : _________________________________
Admission Category: _______________________________Caste :______________________
(SC, ST, OBC, General, GOI etc.)

Religion : __________________________ Nationality : _____________________

of Information Technology

E-mail ID : __________________________________________________________________
Father Occupation : ______________________________________________________________
Mother Occupation : ______________________________________________________________
Sex : Male / Female Married : Yes / No

Academic
Name details:
of Exam. ( 10 Std. Details )
th
: __________________________________________________________________
Board of Exam. : __________________________________________________________________
Name of School: __________________________________________________________________
Exam Roll No. : _____________ Total Marks Obtained: ___________ Maximum Marks:_________
Passing Month : ____________ Year: ________ Percentage Marks Scored: ______Grade:_______
(Note: Attach attested Photocopy of 10 th std marks card)

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 Academic details: ( 12th Std. Details )
Name of Exam. : __________________________________________________________________
Board of Exam. : __________________________________________________________________
Name of School: __________________________________________________________________

E-Max Institute of Information Technology

Exam Roll No. : _____________ Total Marks Obtained: ___________ Maximum Marks:_________
Passing Month : ____________ Year: ________ Percentage Marks Scored: ______Grade:_______
(Note: Attach attested Photocopy of 12th std marks card)

candidate should fill the details of marks obtained in each individual subjects at HSSC/ 12th std
examinations in the following table/ candidate seeking Direct second year admission can write
diploma/degree subjects and marks in the table

Address Details: ( Local Address )

E-Max Institute of Information Technology E-Max Institute

Address :

_________________________________________________________________________
_________________________________________________________________________________
City : __________________ Pin : _____________ Dist. : _______________ State : _____________
Parent’s Landline phone No.: ________________________ Parent’s Mobile No.: ________________
Candidate’s Mobile No:______________________E-mail Id: ________________________________
Nearest Bus Station: _______________________ Railway Station : __________________________

Address Details: (Permanent

( PermanentAddress
Address))

Address : _________________________________________________________________________
_________________________________________________________________________________
City : __________________ Pin : _____________ Dist. : _______________ State : _____________
Parent’s Landline phone No.: ________________________ Parent’s Mobile No.: ________________
of Information Technology

Candidate’s Mobile No:______________________E-mail Id: ________________________________

earest Bus Station: _______________________ Railway Station : __________________________

Last Qualifying Examination Details :

Last Exam Name : ________________________ Exam Year : _______________
Board or Univ. Name : _____________________ Duration of Year : _______________
Total Marks Obtained : ___________ Total Max. Marks : __________ Percentage of Marks : _______
Class : ____________

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 Instructions:
1. 10th std and 12th std attested photocopy of marks sheet to be attached with this form.
2. Affix passport size colour photograph at the space provided in the form
3. Additional sheet can be attached to provide diploma/degree level exam details

I hereby declare that the particulars furnished above are true, complete, and correct to the best of my
knowledge and belief. In the event of any information being found or misleading my admission shall be
liable to cancellation by the institute at any time and I shall not be entitled to refund of fee paid by me to the
institute. I Know that E-Max is an autonomous body and not directly or indirectly associated with any Govt.
dept. E-Max is a Society to Promote Vocational Course Awareness in Indian People. I know the course I am
joining it for self help and self-employment. E-Max or Its Study Center will not give any written guarantee
for job. I understand all the instruction published in prospectus, website and given me verbally. I am agree
with all the terms and conditions. All disputes are subject to kurukshetra jurisdiction only.

Date:
Place: Signature of Student

Study Center seal with Sig.

New Student Registration
Form

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