Auth Code: 776636bf821943f2441e2422cddaafbe 1. Candidate Name: Anirudh Bajaj 2. Parent/Guardian Name: Prem Piyush Bajaj 3.

Date of Birth: 30-10-1993 6. Nationality: Indian 9. First Attempt at JEE: In 2011 12. Enlarged Font Paper Required: No 15. Address: House Number-703 Urban Estate 2 Hissar Haryana 16. PIN Code: 125005 21. Type of Preparation: Self 23. Board of QE: CBSE 25. Parents' Educational Background: Only One Graduate 27. Annual Income of Parent/Guardian: Rs.1,00,000 - 4,50,000 22. Place of 10th Class Schooling: City 24. Mother Tongue: Hindi 26. Occupation of Parent/Guardian: Agriculture 3.5 cm x 4.5 cm with the face covering about 75% of the photo 4. Gender: Male 7. Year of Passing 10th Class: 2009 10. Question Paper Language: English 13. Entitled for DS Seat: No 17. Email ID: anicool.ab@gmail.com 18. Mobile No: 09467252188 19. Landline No: 01662245903 20. PIN Code of Permanent Residence: 125005 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: GE 8. Year of Passing QE: Passed on or after 1st Oct 2010 11. Physically Disabled: No 14. Choice of Exam Cities: I. Rohtak (705) II. Kurukshetra (703)

DECLARATION BY THE CANDIDATE

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 IIT-JEE 2012 Information Brochure (given on IIT-JEE Website) and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2010 or earlier and neither taken admission nor paid the registration fee at any of the IITs / IT-BHU / 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 IIT-JEE 2012 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 : ........................ Name of Parent/Guardian: .............................................................................. Fold Here Candidate Name: Anirudh Bajaj (Signature of the Candidate)

Candidate Signature (Sign within the box only)

(Countersigned by Parent/Guardian) Fold Here

AXIS BANK
( TO BE FILLED IN BY BANK)

JEE COPY

Address: House Number-703 Urban Estate 2 Hissar Haryana PIN Code: 125005 Mobile No: 09467252188 Total Payable in Figures (Including Bank Charges): Rs. 1610.00 Total Payable in Words (Including Bank Charges) Rupees:

Application Form No: C27121670 Date of Birth: 30-10-1993 IIT-JEE 2012 Account No: 911020051391279 Challan No: 33057695 Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)

One Thousand Six Hundred and Ten Only

Date of Deposit: (Signature of the Candidate)

........./.........../ 2011

(Authorised Signatory) CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT ROORKEE TO COMPLETE YOUR APPLICATION

Candidate Name: Anirudh Bajaj

AXIS BANK
( TO BE FILLED IN BY BANK)

BANK's COPY

Address: House Number-703 Urban Estate 2 Hissar Haryana PIN Code: 125005 Mobile No: 09467252188 Total Payable in Figures (Including Bank Charges): Rs.1610.00 Total Payable in Words (Including Bank Charges) Rupees:

Application Form No: C27121670 Date of Birth: 30-10-1993 IIT-JEE 2012 Account No: 911020051391279 Challan No: 33057695 Branch Code: Tran. No / Journal No: Branch Seal (Within the box only)

One Thousand Six Hundred and Ten Only

Date of Deposit:

........./.........../ 2011
(Authorised Signatory)

(Signature of the Candidate)

JEE COPY

IIT-JEE 2012

INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012

Application Form No.

C27121670

IIT-JEE 2012
Indian Institutes of Technology

BY REGISTERED POST / SPEED POST ONLY

Application Form No.

Choice - I Your Choice of Examination Cities

Choice - II

705

703

APPLICATION FORM NO :

C27121670
To

From Name :
Anirudh Bajaj

The Chairman Joint Entrance Examination 2012

Address :

House Number-703 Urban Estate 2 Hissar Haryana

Indian Institute of Technology Roorkee Roorkee PIN Code - 247667

PIN Code : Landline : Email :

125005 01662245903

Mobile :

09467252188

anicool.ab@gmail.com

CUT HERE AND PASTE THE UPPER PART ON A5 ENVELOPE

PLEASE INSERT THE APPLICATION FORM IN THE ENVELOPE IN SUCH MANNER THAT THE BARCODE ON THE APPLICATION FORM IS NOT FOLDED. CHECKLIST FOR THE CANDIDATE
1. Tick the box if you have enclosed the following documents:
a. Completed Application Form with your and parent / guardian's signature. b. Your colour photograph (of size 3.5 cm x 4.5 cm) affixed on application appropriately. c. Attested copy of 10th class certifiate for Date of Birth. d. Attested copy of category certificate if you belong to SC/ST/OBC(NCL). e. Request letter for enlarged font question paper if you have poor vision.

2. Retain a photocopy of the completed application form with you. 3. Send your application form to the IIT as mentioned on the address slip.