Enrollment Form Fiitjee

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<p>En r o l m e n t F o r m(for Classroom / Integrated School Programs)</p> <p>Enrolment Number (for official use only)</p> <p>Instruction for filling Enrolment FormPlease read carefully the Important Information for Students (&amp; their Parents / Legal Guardians) and Declarations / Undertakings section on page no. 9, 10 &amp; 11 respectively before filling this Form.</p> <p>Please Note :v Check the availability of the program at your preferred FIITJEE centre before making a choice. v Make a photocopy of this form after filling the required information and before submitting it to FIITJEE. v Log on to www.fiitjee.com/regupdate.htm to update your Contact Details online using Registration Number and web access code printed on your Hall Ticket.</p> <p>Items required to be submitted along with this form :v Six identical passport size colour photographs of the student (One photograph should be pasted on this page, Two on page no. 13 and Three photographs should be submitted along with this Enrolment Form). v One stamp size photograph (should be pasted on page no. 13). v Admission Test / FTRE / FTSE / Fortunate - 40 Hall Ticket (in Original). v Admission offer letter (in Original). v Any one of the following documents : n Photocopy of School ID card with photograph or n Photocopy of last Board or School Marksheet supported by any Identity Proof of student or n Photocopy of Transfer Certificate or n Bonafide certificate issued by the Principal of School with students photograph Original should be presented for verification at the time of admission.</p> <p>Enrolment Form</p> <p>Test date : ______/______/_____________Please affix the 1st passport size colour photograph of the student here</p> <p>Registration Number (as mentioned on the Hall Ticket):_______________________________________________ Study Centre Program Name (refer page no. 13 &amp; 14) Program Code (refer page no. 13 &amp; 14) Scholarship Awarded % (if applicable) : _________________________________________________________</p> <p>: ________________________________________________________________________ : ________________________________________________________________________ : ________________________________________________________________________</p> <p>Students Name (in Block Letters) Date of Birth Mailing Address</p> <p>: _______________________________________________________________________________________ : ________/_______/___________ E-mail ID :_________________________________________________ : _______________________________________________________________________________________</p> <p>________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________ Pin : _________________________________ Contact No (Mobile) Permanent Address (if any) : ____________________________ Land Line (with STD Code) : ___________________________________ : _______________________________________________________________________________________</p> <p>________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________ Pin :_________________________________ Contact No. (Mobile) : ____________________________ Land Line (with STD Code) : ___________________________________</p> <p>School/College Last Attended / Presently Attending : _____________________________________________________________________ Address : _______________________________________________________________________________________</p> <p>_________________________________________________________________________________ Pin : _________________________________</p> <p>(a) Fathers Name Occupation :</p> <p> Business </p> <p>: ________________________________________________ Qualification : _________________________ Govt. Service Pvt. Service Others (please specify) : __________________________</p> <p>Name of the Company / Office : _______________________________________________________________________________________ Nature of Business / Job Department Office / Business Address : ____________________________ Designation : _____________________________________________ : ____________________________ Contact No (office) : _________________________________________ : _______________________________________________________________________________________</p> <p>_________________________________________________________________________________ Pin : _________________________________ E-Mail ID : ________________________________________________ Mobile No : ___________________________</p> <p>(b) Mothers Name Occupation : Business </p> <p>: ________________________________________________ Qualification : _________________________ Govt. Service Pvt. Service Others (please specify) : __________________________</p> <p>Name of the Company / Office : _______________________________________________________________________________________ Nature of Business / Job Department Office / Business Address : ____________________________ Designation : _____________________________________________ : ____________________________ Contact No (office) : _________________________________________ : _______________________________________________________________________________________</p> <p>_________________________________________________________________________________ Pin : _________________________________ E-Mail ID : ________________________________________________ Mobile No : ___________________________3</p> <p>Enrolment Form</p> <p>(c) Details of the Local Guardian reference (Mandatory if the student is joining as a hosteler)Local Guardians Name Occupation : Business : ________________________________________________ Qualification : ________________________ Govt. Service Pvt. Service Others (please specify) : __________________________</p> <p>Name of the Company / Office : _______________________________________________________________________________________ Nature of Business / Job Department Office / Business Address : ____________________________ Designation : _____________________________________________ : ____________________________ Contact No (office) : _________________________________________ : _______________________________________________________________________________________</p> <p>_________________________________________________________________________________ Pin : _________________________________ E-Mail ID Mailing Address : ________________________________________________ Mobile No : ___________________________ : _______________________________________________________________________________________</p> <p>________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________ Pin: _________________________________</p> <p>(d) Details of the Sibling(s)1. Name Class studying in </p> <p>(if applicable)</p> <p>: _______________________________________________________________________________________ : ___________________________ Enrolment No. (if enrolled with FIITJEE) :_________________________</p> <p>2. Name Class studying in </p> <p>: _______________________________________________________________________________________ : ___________________________ Enrolment No. (if enrolled with FIITJEE) :_________________________</p> <p>3. Name Class studying in </p> <p>: _______________________________________________________________________________________ : ___________________________ Enrolment No. (if enrolled with FIITJEE) :_________________________</p> <p>Details of the examination(s) of the class last passed / currently studyingName of the Examination(s) Board Year of passing / appeared Total Aggregate Marks (%) PCM / Science + Math (%)</p> <p>Fee Details : </p> <p>Fee Plan opted (): Fee Plan Code(please refer course fee Annexure)</p> <p>I </p> <p>II </p> <p>III </p> <p>: _______________________________________</p> <p>Detail(s) of Demand Draft(s) / Pay Order(s) S. No.1 2 3 4 Total</p> <p>Instrument Number</p> <p>Dated</p> <p>Issuing Bank &amp; Branch</p> <p>Amount (in Rs.)</p> <p>4</p> <p>Enrolment Form</p> <p>Annexure A TERMS &amp; CONDITIONS FOR POST DATED CHEQUE(S)I understand that if my son /daughter / ward withdraws from the Program to which he/she has been admitted at any point of time or does not attend the Program and thus the seat given to him/her is rendered vacant, the same will not/can not be filled up by any other candidate and a vacancy created in the batch due to withdrawal of a student after the starting of classes or up to 2 days prior to the same cannot be filled in any case, therefore I understand that FIITJEE shall suffer irreparable losses in case of non-payment of remaining fee of the installment plan, hence it will be unethical not to honor the Post Dated Cheque(s). I have opted for installment fee plan and have submitted the Post Dated Cheque(s) as per the details give below. I agree that, I will make arrangement, for below stated Post Dated Cheque(s), to get honored, and will keep sufficient funds on or before the due date for the same. Detail(s) of Post Dated Cheques (Only Local / Payable at par cheques will be accepted) S. No.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24</p> <p>Affix one self attested passport sized photograph of the person issuing Post Dated Cheque(s) i.e. parents / guardian</p> <p>Cheque No.</p> <p>Dated</p> <p>Issuing Bank</p> <p>Fee Amount</p> <p>S. Tax Amount</p> <p>Total Amount</p> <p>I further agree to get above Post Dated Cheque(s) cleared, even if, my son / daughter / ward discontinues studies at FIITJEE, irrespective of any reasons. I am signing the above declaration in good mental / physical health. I have satisfied myself about FIITJEE. The necessary Enrolment-Forms, including this form was received by me several days before the actual date of signing to enable me to understand the implications of taking admission at FIITJEE. I have taken expert opinion regarding matters which were not clear to me and I am satisfied.</p> <p>Signature of the Student </p> <p>Name : ____________________________________________________ Enrolment Number (for office use only) : __________________________ </p> <p>Father / Mother / Legal Guardians Signature {Who has issued the cheque(s)} Name : ______________________________________ Address : ____________________________________</p> <p>Date : _____________________________________________________</p> <p>I have retained photocopy of this document for my reference before submitting it at FIITJEE. Date : _________________________________ Place : _________________________________ 5</p> <p>Father / Mother / Legal Guardians Signature Name : ______________________________________</p> <p>Enrolment Form</p> <p>Annexure B CONSEQUENCES OF DISHONOUR OF POST DATED CHEQUE(s)I understand that non-clearance of any of the Post Dated Cheque(s), submitted for payment of fees (on installment basis) as mentioned in the Enrolment-Form and annexure B is punishable under Sec. 138 (B) of the Negotiable Instrument Act. I understand that FIITJEE shall be entitled to proceed and initiate appropriate legal action against me, to recover the amount of the Post Dated Cheque(s) along with the legal expenses and out of pocket expenses incurred by FIITJEE. In case any of my Post Dated Cheque(s) bounces for any reason whatsoever, I undertake to submit a DD/Pay-Order in favour of FIITJEE Ltd. payable at New Delhi, within four days of the bouncing of the Cheque(s) at my bank, together with Rs. 500/- (Rupees five hundred only) as default money alongwith late payment of Rs. 50/- (Rupees fifty only) per day upto 10 (Ten) days from the due date of payment of instalment after which my son / daughter / ward shall be debarred from classes without any further notice and I shall have no claim for refund of fees or any support in studies besides Legal action inter alia action under Section 138 (B) of the Negotiable Instrument Act may be initiated against me/us.</p> <p>Signature of the Student </p> <p>Name : ____________________________________________________ Enrolment Number (for office use only) : __________________________ </p> <p>Father / Mother / Legal Guardians Signature {Who has issued the cheque(s)} Name : ______________________________________ Address : _________________________________________________________________________________</p> <p>Date : _____________________________________________________ </p> <p> _____________________________________________ </p> <p>I have retained photocopy of this document for my reference before submitting it at FIITJEE.</p> <p>Date : _________________________________ Place : _________________________________</p> <p>Father / Mother / Legal Guardians Signature Name : ______________________________________</p> <p>6</p> <p>Enrolment Form</p> <p>Annexure C PARENT DATA SHEET(CONFIDENTIAL) Dear Parent / Guardian, The right and accurate feed back of your ward/student will give us an opportunity to understand the student better which will help us in providing better support &amp; education. This information will be confidential.</p> <p>1. Name of the Student 2. Fathers/Guardians Name 3. Relation with Student</p> <p>: ______________________________________________________________________________ : ______________________________________________________________________________ : ______________________________________________________________________________</p> <p>4. How would you rate the student in the following characteristics ? ( the appropriate)Excellent Sincerity Leadership Imagination Emotional stability Ability to work with others Ability to work hard Perseverance Good Average Below Average Low Unknown</p> <p>6. What is the students class rank? : ____________________________________________________________________________ 7. Some gifted individuals make mediocre scholastic records. Is the students record an accurate index of his/her capabilities? Yes / No If no, state why? : ______________________________________________________________________________</p> <p>8. What is the students biggest weakness? : ______________________________________________________________________ 9. Have there been any major changes in the students attitude towards studies till now at any time, if so illustrate, when and why?(You may attach a blank page if required.)</p> <p>10. Please mention any other information relating to the student, which help make FIITJEE understand the student better. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________</p> <p>11. My son / daughter / war...</p>