REGISTRATION FORM by xld14276

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									                                     REGISTRATION FORM
                          FORTUNATE 40 Selection Test – 15th November, 2009
Registration No:
(for Office Use Only)


Personal Particulars (Please fill the details below)
1.    Name of the Student                         :

2.    Father’s / Guardian’s Name                  :
                                                                                                               Paste your recent
3.    School Name (Presently Attending) :                                                                      passport size color
                                                                                                               photograph here and
                                                                                                               attach one additional
                                                                                                               photograph with the
4. School Address                                     :                                                        application form.

                                                          :

                                                Pin:

5.    Board (School Affiliated to)                        :

6.    Mobile / Contact No                                 : (i)                                  (ii)

7.    E-Mail Address                                  :

8.    Class presently Studying In                     :               VIII                                 X
      {Please tick ( )}


9.    Last Final School Exam Aggregate Marks (%):                                      Date of Birth:

10. Correspondence Address                                :




                                               Pin :                          Phone:

11. Permanent Address                                     :




                                              Pin :                                    Phone:

12. Occupation                             Father :                                             Mother :

13. Please tick ( ) against the Code / Segment you belong to.

      CODE                                                        SEGMENT* (for IIT-JEE Aspirants)                             Select

       9004             Fortunate - 40 Test for Students presently in Class VIII (Going to class IX)

       1104             Fortunate - 40 Test for Students presently in Class X (Going to class XI)


      CODE                                                        SEGMENT* (for Medical Aspirants)                             Select

       9005             Fortunate - 40 Test for Students presently in Class VIII (Going to class IX)

       1105             Fortunate - 40 Test for Students presently in Class X (Going to Inter Ist Year (XI))
* For details of relevant Programs, please refer Fortunate - 40 Brochure.
 14. Please tick ( ) against the centre where you are submitting the Registration form and against the Study centre* where
     you wish to enroll in FIITJEE classroom program.

                                       Select the Select the                                                      Select the Select the
            CENTRE               CODE Registration  Study                            CENTRE               CODE   Registration  Study
                                        Centre     Centre*                                                         Centre     Centre
 Amritsar                          17                                     Hyderabad (Basherbagh)           57
 Bangalore                         55                                     Indore                           48
 Bhilai                            46                                     Jaipur (Hawa Sadak)              31
 Bhopal                            47                                     Jaipur (Vaishali)                32
 Bhubaneswar                       73                                     Kanpur                           24
 Bokaro                            83                                     Kolkata (Rabindra Sadan)         71
 Chandigarh                        16                                     Kolkata (Ultadanga-Salt Lake)    72
 Chennai (Adyar)                   62                                     Lucknow                          22
 Chennai (Kilpauk)                 61                                     Mumbai (Andheri)                 42
 Chennai (Sriperumbudur)           63                                     Mumbai (Chembur)                 43        NA
 Delhi (East)                      13                                     Mumbai (Dadar)                   41
 Delhi (Janak Puri)                14                                     Mumbai (Kandivali)               44
 Delhi (North-West)                12                                     Mumbai (Navi Mumbai)             45
 Delhi (Rohini)                    15                                     Mumbai (Thane)                   40
 Delhi (South)                     11                                     Nagpur                           49
 Delhi (Dwarka)                    10                                     Patna                            81
 Delhi NCR (Faridabad)             19                                     Pune                             39
 Delhi NCR (Gurgaon)               18                                     Raipur                           38
 Delhi NCR (Noida)                 21                                     Ranchi                           82
 Dhanbad                           84                                     Shakti Nagar_NTPC                23
 Durgapur                          74                                     Vadodra                          33
 Hyderabad (Dilsukh Ngr)           52                                     Varanasi                         25
 Hyderabad (Kukatpally)            53                                     Visakhapatnam                    54
 Hyderabad (Saifabad)              51                                     Other Centre                     00                   NA
* For Study Centre of your relevant program, please refer Fortunate - 40 Brochure

15. Please tick ( ) against the Test centre where you wish to write the test.

                                                      Test Centre                                                    Code      Select
 Amritsar - FIITJEE Ltd., 3rd Floor, SCO : 31, District Shopping Centre, B-Block, Ranjit Avenue                       170
 Anantapur - Springdale English Medium High School, 12-4-480, Obuladeva Nagar,                                        923
 Asansol - India International School, Kalyanpur Satellite Township (KSTP)                                            718
 Bangalore - Banjara Academy, 418, 1st Main, 1st Block, R T Nagar                                                     553
 Bhilai - MGM School, Sector – 6                                                                                      462
 Bhopal - FIITJEE Ltd., 48 - A, 3rd Floor, Guru Kripa Plaza, Zone II, M.P. Nagar                                      470
 Bhubaneswar - Kasturiba Shikshasharam, Plot No : 695, Opp. Nabard Bank, Nayapalli,                                   822
 Bidar - Shahen School & PU College, Shaheen Education Centre, Ahmed Bagh, Golekhana, Bidar                           533
 Bokaro - D.A.V. Public School, Sec. 4, Bokaro Steel City                                                             831
 Chandigarh - Mount Carmel Convent School, Sector 47                                                                  161
 Chennai (Kilpauk) - Maharishi Vidya Mandir Sr. Sec School , No. 28, Dr. Gursamy Road , Chetpet                       611
 Chennai (Adyar) - Kumararani Meena Muthiah Mat. Hr. Sec. School, Gandhi Nagar,                                       623
 Chennai (Sriperumpudur) - Maharishi International Residential School, Santhavelur Sunguvar Chatram                   613
 Delhi (South) - Suraj Bhan D.A.V. Public School, F – 10/15, Poorvi Marg, Vasant Vihar                                112
 Delhi (North West) - DL D.A.V. School, BN Block, Shalimar Bagh                                                       152
 Delhi (East) - Lovely Public Senior Secondary School, Priyadarshini Vihar                                            131
 Delhi NCR (Gurgaon) - Blue Bells Model School, Sector-4, Gurgaon                                                     182
 Delhi NCR (Noida) - Lord Mahavira School, Sector – 29, Noida                                                         211
 Dhanbad - Delhi Public School, Karmik Nagar, P.O. - I.S.M.                                                           832
 Durgapur - D.A.V. Model School, J. M. Sengupta Road                                                                  713
                                                        Test Centre                                                                Code         Select
 Gulbarga - Sharanabasaveshwar Residential Public School, Sharan Nagar,                                                             534
 Hyderabad (Saifabad) - FIITJEE Ltd. 5-9-14/B, Saifabad (Opp. Secretariat)                                                          510
 Hyderabad (Dilsukhnagar) - FIITJEE Ltd., D. No: 16-11-477/6/2/2, Sahadeva Reddy Buildings, Lane
                                                                                                                                    520
 besides Sahadeva Reddy Sweets, Dilsukhnagar
 Hyderabad (Kukatpally) - FIITJEE, H.No.22-97, Plot No.1, Opp. Patel Kunta Huda Park, Vijaynagar Clny                               530
                                  nd
 Indore - FIITJEE Ltd., 27, 2          Floor, Scheme No. 54, PU–3, Opp.Orbit Mall, Commercial Bhamori, A.B Rd                       480
 Jaipur - Step By Step High School, Near Chitrkoot Stadium, Vaishali Nagar                                                          311
 *Kalpakkam - Atomic Energy Central School No. 2, D A E Town Ship, Sadras                                                           627
 Kanpur - B. N. S. D. Siksha Niketan Inter College, Benajhabar, Opp. Jal Sansthan                                                   221
 Karimnagar - Gowthami English Medium School (GEMS), Kaman Area,                                                                    517
 Khammam - R R High School, By Pass Road,                                                                                           518
 Kolkata - St. Joseph’s College, 7, Gopi Bose Lane                                                                                  712
 Kurnool - Sri Sankara’s Degree College No-9, Gayathri Estate,                                                                      529
 Lucknow - FIITJEE Ltd., Scholar’s Home (Inter College), Vipul Khand – 3 , Gomti Nagar                                              220
 Mumbai (Sion) – D.S. High School, Near SIES College, Sindhi Colony, Near Sion Bus Depot, Sion (W)                                  412
 Mumbai (Kandivali) – Thakur College Of Science & Commerce, 5th Flr, Thakur Village, Kandivali(E)                                   441
 Mumbai (Thane) - Bedekar Vidhyalaya, Naupada, Thane (W)                                                                            401
 Nagpur - CP & Berar College, Tulsibag Mahal, Nagpur                                                                                117
 Nizamabad - Gowtham Concept School, Gangastan,                                                                                     534
 * Neyveli - Sri Aurobindo Vidyalaya Mat. Hr. Sec. School Block                                                                     626
 Patna - Model St. Michael’s High School, Budha Colony, Patna                                                                       814
 Pune - Sir Parashurambhau College, Sadashiv Peth, Tilak Road                                                                       118
 Ranchi - Jawahar Vidya Mandir, Shyamali, P.O. – Doranda                                                                            821
 Siliguri - Bright Academy, Guru Nanak Sarani, Punjabi Para                                                                         716
 Shaktinagar (NTPC) - FIITJEE Ltd.Employee Development Centre, Hostel No.-3 NTPC, Dist. Sonebhadra                                  230
 * Trichy - Carmel Matriculation School, Carmel Garden, Ramalinga Nagar West Extension, Woriyur                                     628
 * Trivandrum - Govt Girls Hr. Sec. School, Cotton Hills, Vazhthacaud                                                               616
 Vadodara - Alembic Vidyalaya, Alembic Colony, Gorwa Road, Vadodara                                                                 911
 Varanasi - Govt. Queens Inter College, Lahurabir                                                                                   224
 Visakhapatnam - Bhashyam Public School, Dwarakanagar                                                                               541
 Warangal - St. Peter’s Central Public School, Old Bus Depot Road, Hanamkonda,                                                      513
* For Registrations at Kalpakkam, Neyveli, Trichy & Trivandrum, log on to registration portal www.fiitjee.com/f40.htm download the Registration Form
& send by courier to FIITJEE Chennai (Kilpauk) Centre. Your admit card will be issued & send to your correspondence address.


How to Register               :    Fill in your complete details in the prescribed form of FORTUNATE 40, mentioning test centre,
                                   preference of study centre & program code alongwith the photocopy of last school exam
                                   marksheet / school identity card, two passport size colour photographs and submit it to
                                   nearest FIITJEE centre.

Registration is open at all FIITJEE Centres viz. :
                                  Delhi {South Delhi (46106000), North-West Delhi (45634000), Janak Puri (45616600) & Rohini
                                  (47064000), East Delhi (43002500)}, Delhi NCR {Gurgaon (4628400) & Noida (3105005)};
                                  Amritsar (3203344) ; Bangalore (41135682) ; Bhilai (3205808) ; Bhopal (4253355) ; Bokaro
                                  (325511) ; Chandigarh (3010043); Chennai {Kilpauk (42859701), Adyar (64609556),
                                  Sriperumpudur (42859701)} ; Hyderabad {Saifabad (66777000), Dilsukhnagar (64569509) &
                                  Kukatpally (64601123)} ; Indore (4274702) ; Jaipur {Hawa Sadak (5181885), Vaishali (4082333)};
                                  Kolkata {Rabindra Sadan (30537576) & Ultadanga-Salt Lake (40221300)} ; Lucknow (2302533) ;
                                  Mumbai {Dadar (32666214), Kandivali (32683438), Chembur (32666214), Andheri (32666214),
                                  Navi Mumbai (32666214), Thane (41617777)} ; Patna (3299798) ; Ranchi (2563188);
                                  Shaktinagar NTPC (232366) & Visakhapatnam (2555501).

Selection Test Date                              :          15th November, 2009

Last Date to Register                            :          12th November, 2009

Registration Fee for the Test                    :          Nil
Eligibility to appear in Selection test
        1.   The student should be presently studying in Class VIII / X and be an aspirant of IIT-JEE / PMT, 2014 & 2012.
        2.   The student should be from Central Government, State Government School for under privileged class for example
             students studying in Navodaya Vidyalaya Samiti Schools. The total parental income should be below Rs. 10,000/- per
             month.

                                                    Self Declaration of Parental Income:

    We.……………………………………………………….. (Father) & ….…………………………………………… (Mother) of
    ……………………………….……………………….……. (Name of Student) who will be appearing in Fortunate 40
    Examination to be held on 15th November, 2009, hereby declare that our joint income is Rs….....………….…per month
    Rs.…………………..…………………………………………………………………………………….… (in words) per month

    If at any stage, it is found that the above information given by us is false / not true, all the benefits given to our ward
    attached with Fortunate – 40 Examination to be held on 15th November, 2009 will be withdrawn and legal action as
    deemed fit, may be taken against us and my ward.

    Signature : _______________________________ (Father) ____________________________________ (Mother)

    Name          : _______________________________ (Father) ____________________________________ (Mother)

    Date          : _____________________                                                    Place     _____________________



Documents Required              : Selected students will have to submit the following documents at the time of taking admission:
(at the time of admission)
                                   1.       Marksheet of last class attended.
                                   2.       Certificates of achievements (if any).
                                   3.       Residence proof (Ration card / Passport / Election ID Card of parents).
                                   4.       Income proof of both parents as given below:
                                        (a) Salary Slip of last month (if employed in a private firm / Government / Semi Government organisations).
                                        (b) Affidavit / self declaration form (as per requisite format) duly attested by any one of the following –
                                            Honorable President, Prime Minister, Minister of Home, Minister of Foreign Affairs, Minister of
                                            Education at the Centre, Supreme Court & High Court Judge, Cabinet Secretary, Home Secretary,
                                            Foreign Secretary, Education Secretary at the Centre, Chief Minister, Home Minister or Education
                                            Minister for the State, District Police Chief (City Chief in case of Metro), General Manager or above
                                            rank of Nationalised Bank, District Income Tax Chief (City Chief in case of Metro) / Assistant
                                            Commissioner & Above rank.



I hereby declare that the information furnished on this Registration Form is correct to the best of my knowledge and belief.


Place        : ____________________
                                                                                                                 ___________________________________
Date         : ____________________
                                                                                                                (Signature of the Student / Parent / Guardian)
Registration Form Checked by: _______________________________________ Signature: _______________________ Date: __________________
(for office use only)


Terms and Conditions:
Note 1 :       Fee waivers for FIITJEE program & hostel fee concessions will be decided on the basis of performance and subject to scoring above
               minimum cut-off marks in each subject and minimum cut-off marks in aggregate.
Note 2 :       The final discretion of award of fee waivers for FIITJEE programs & hostel fee concessions in each case will remain with FIITJEE
               management and this decision will be final and binding on the candidate.
Note 3 :       Fee waivers for FIITJEE programs & hostel fee concessions are valid for the select mentioned programs only.
Note 4 :       Hostel fee waivers are valid only for FIITJEE’s associate hostels / lodging and boarding facilities made available through FIITJEE,
               subject to the student joining that particular hostel and availability of seats. The hostel fee waivers are valid till the duration of the
               FIITJEE program.
Note 5 :       FIITJEE reserves the right to change / cancel any program, eligibility criterion without prior notice.
Note 6 :       The registered office of FIITJEE Limited is at New Delhi. In case of dispute, students / parents are subject to the exclusive jurisdiction
               of appropriate courts in Delhi / New Delhi only. All disputes shall be referred to the Sole Arbitrator appointed by the Management of
               FIITJEE Ltd. The decision of the arbitrator shall be final & binding. The arbitrator so appointed shall not be incapacitated for reasons
               of their being the employee of FIITJEE Ltd. or its sister concern, and for reasons of having any prior linkage with the company. The
               seat of arbitration will be Delhi.

            National Admissions Office: FIITJEE House, 29–A, Kalu Sarai, Sarvapriya Vihar, New Delhi - 110016
  Ph: 011-46106000, 26515949, 26569493 All India Toll Free No.: 1800 11 4242 Fax : 011-26513942 Web : www.fiitjee.com

								
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