Auth Code: a5c9472d73e161cf38a4686b30e91f62 1. Candidate Name: Ravi Sharma 2. Parent/Guardian Name: Rakesh Sharma 3. Date of Birth: 15-08-1993 6.

Nationality: Indian 9. First Attempt at JEE: In 2012 12. Enlarged Font Paper Required: No 15. Address: C/O Rakesh Sharma 1011 , Suzuki Building Elektra Street Abu Dhabi Uae 16. PIN Code: 000000 21. Type of Preparation: Self 23. Board of QE: CBSE 25. Parents' Educational Background: Both Graduates 27. Annual Income of Parent/Guardian: Above Rs. 4,50,000 22. Place of 10th Class Schooling: City 24. Mother Tongue: Hindi 26. Occupation of Parent/Guardian: Engineering 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: 2010 10. Question Paper Language: English 13. Entitled for DS Seat: No 17. Email ID: sachingsaini@gmail.com 18. Mobile No: 00502276275 19. Landline No: 97143370568 20. PIN Code of Permanent Residence: 000000 PASTE RECENT COLOR PHOTOGRAPH HERE 5. Category: GE 8. Year of Passing QE: Appearing in 2012 11. Physically Disabled: No 14. Choice of Exam Cities: I. Dubai (217) II. Dubai (217)

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: Ravi Sharma ( DEMAND DRAFT DETAILS ) (Signature of the Candidate)

Candidate Signature (Sign within the box only)

(Countersigned by Parent/Guardian) Fold Here

JEE COPY

Address: C/O Rakesh Sharma 1011 , Suzuki Building Elektra Street Abu Dhabi Uae PIN Code: 000000 Mobile No: 00502276275 Total Payable in Figures: Total Payable in Words:

Draft No: Draft Date: ........./.........../ 2011

USD 200.00

USD Two Hundred Only

CUT HERE AND SEND THE UPPER PART TO JEE OFFICE IIT DELHI TO COMPLETE YOUR APPLICATION

JEE COPY

IIT-JEE 2012

INDIAN INSTITUTES OF TECHNOLOGY JOINT ENTRANCE EXAMINATION - 2012

Application Form No.

C22400011

IIT-JEE 2012
Indian Institutes of Technology

BY REGISTERED POST / SPEED POST ONLY

Choice - I Your Choice of Examination Cities

Choice - II

217

217

APPLICATION FORM NO :

C22400011
To

From Name :
Ravi Sharma

The Chairman Joint Entrance Examination 2012

Address :

C/O Rakesh Sharma 1011 , Suzuki Building Elektra Street Abu Dhabi Uae

Indian Institute of Technology Delhi Hauz Khas, Delhi PIN code - 110016

PIN Code : Landline : Email :

000000 97143370568

Mobile :

00502276275

sachingsaini@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. 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.