Instructions for Candidate:-

1. There are 5 sheets in this file.

2. This sheet (Sheet - 1) is to be retained by you carefully.
3. Your Login id is MAHI1108
4. Remember your password and do not disclose it to anyone.
5. Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to IIT KANPUR ZONE
a. Stick your color photo at the designated place.
b. Put your signature at the two designated places.
c. Get the signature of your Parent / Guardian at the designated place.
6. Sheet - 3 is the Application Form and should be retained by you for your reference.
7. You have selected NEFT mode for payment. The details for the fund transfer are in Sheet 5 of this form.At the end
of fund transfer, note down the Unique Transaction ID/ Reference no. (UTR) in the top left corner of the Application
form (Sheet 2).
8. Attach attested copies of Tenth Class/SSLC certificate where your date of birth is mentioned clearly, and all other
applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9. Insert completed Application Form with enclosures (if any) into an A4 size envelope. DO NOT FOLD THE
APPLICATION.
10. Sheet - 4 contains the address of the IIT KANPUR ZONE
to which the application form needs to be posted.
11. Stick the Sheet-4 on top of the A4 size envelope and post it.
12. The packet should reach the corresponding zonal IITs on or before 20th December 2010.

Sheet - 1
 IIT COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B341038240 Zone: IIT KANPUR ZONE Payment Mode: NEFT (UTR ____________________ )

1. Name of the Candidate as in MAHIMA MISHRA 17. Name of one Parent / CHANDRA BHOOSHAN MISHRA
the 10th Class Certificate Guardian
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling TOWN
3. Gender FEMALE
19. Type of Preparation SELF STUDY
4. Nationality INDIAN
20. Board of Qualifying STATE BOARD
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 09993457175
Time Number
22. Mother Tongue Hindi
In the above examination did you Yes
obtain qualifying marks? 23. Pincode or Permanent 486001
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Public / Govt. Service
7. Sub Category None Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 11/08/1994 26. Parent's / Guardian's Total Rs.1,00,000 - 3,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 403 - Jabalpur
Cities 401 - Bhopal
12. Counselling IIT KANPUR

13. Question Paper Language HINDI

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquired is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place:

Date:
Signature of the Candidate
Name of the Parent / CHANDRA BHOOSHAN MISHRA
Guardian
Name of the Candidate MAHIMA MISHRA
Countersigned by Parent / Guardian

14. Address:- C B MISHRA 15. Photograph

WNO 15 HNO 2012 BEHIND BAL COURT

SHIV PD DUBEY MARG SAMAN

REWA
Please write
Phone / Mobile 09993457175 your name and
Number application
Pincode 486001 number on the
back of photo
E-Mail Address vagrawal79@rediffmail.com before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B341038240 black ball point pen only (do not sign in capitals)
Send this form along with the necessary documents to IIT KANPUR ZONE

Sheet - 2
 CANDIDATE COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B341038240 Zone: IIT KANPUR ZONE Payment Mode: NEFT (UTR ____________________ )

1. Name of the Candidate as in MAHIMA MISHRA 17. Name of one Parent / CHANDRA BHOOSHAN MISHRA
the 10th Class Certificate Guardian
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling TOWN
3. Gender FEMALE
19. Type of Preparation SELF STUDY
4. Nationality INDIAN
20. Board of Qualifying STATE BOARD
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 09993457175
Time Number
22. Mother Tongue Hindi
In the above examination did you Yes
obtain qualifying marks? 23. Pincode or Permanent 486001
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Public / Govt. Service
7. Sub Category None Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's BOTH PARENTS GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 11/08/1994 26. Parent's / Guardian's Total Rs.1,00,000 - 3,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 403 - Jabalpur
Cities 401 - Bhopal
12. Counselling IIT KANPUR

13. Question Paper Language HINDI

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquired is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place:

Date:
Signature of the Candidate
Name of the Parent / CHANDRA BHOOSHAN MISHRA
Guardian
Name of the Candidate MAHIMA MISHRA
Countersigned by Parent / Guardian

14. Address:- C B MISHRA 15. Photograph

WNO 15 HNO 2012 BEHIND BAL COURT

SHIV PD DUBEY MARG SAMAN

REWA
Please write
Phone / Mobile 09993457175 your name and
Number application
Pincode 486001 number on the
back of photo
E-Mail Address vagrawal79@rediffmail.com before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B341038240 black ball point pen only (do not sign in capitals)

Sheet - 3
APPLICATION FORM NO B 3 4 1 0 3 8 2 4 0 BY REGISTERED POST/
SPEED POST
FOR Rs. 450 /-

JEE - 2011
Indian Institutes of Technology

Your Choice Choice - I Choice - II

of Cities
for JEE - 2011 403 401

To
From
Name MAHIMA MISHRA
The Chairman
Address Joint Entrance Examination - 2011
Indian Institute of Technology - IIT KANPUR ZONE
C B MISHRA

WNO 15 HNO 2012 BEHIND BAL COURT IIT KANPUR

SHIV PD DUBEY MARG SAMAN KANPUR

REWA

Pin 4 8 6 0 0 1

Phone/Mobile: 09993457175
Email (if any) : vagrawal79@rediffmail.com Pin 2 0 8 0 1 6

Sheet - 4
 JEE-2011 NEFT Transaction

1. Payee / Beneficiary / Recipient Bank Name : Indian Bank

2. Payee / Beneficiary / Recipient Branch Name : Adyar

3. Bank's IFSC Code: IDIB000A002

4. Payee / Beneficiary / Recipient Name: I I T (MADRAS) JEE-2011 (NEFT A/C)

5. Payee / Beneficiary / Recipient Account No : 910646450

6. Payee / Beneficiary / Recipient Account Type: Current Account

7. Application Fee (Exclusive of other bank Rs. 450 /-

charges):

Please enter your name and application number (B341038240) in the Remitter's Account Details/Customer
Transaction Details or equivalent fields in the NEFT request form

The counterfoil from bank or confirmation for Internet Transfer (UTR number) should be attached with this
sheet and sent to IIT

Sheet - 5