GOVERNMENT OF NATIONAL CAPITAL TERRITORY OF DELHl DIRECTORATE OF EDUCATION: SCHOOL BRANCH OLD SECRETARIAT DELHI-1I0054

No.DE.2J(455)/Sch.Br./NGOW ?--",O Dated::5?- h ~ CIRCULAR

Subjects- Regarding Outreach in Government Sponsored/afilliated schools in for "Fortunate 40"-a social initiative of FUTJEE to help & support economically deprived students.

Please find enclosed herewith the proposal alongwith application form received from Mr./Ms. Partha Halder, Director-Academics FIITJEE Ltd on the above subject

All Head of Schools are directed to inform the students about the programme which is specially meant for those students whose parental incomes is less than Rs. 1.20 lakh p.a. FliT JEE has informed that 40 selected students (each of classes VIII & X) will be supported by them by means of classroom coaching for various entrance exams. Those who do not get selected as "Fortunate-40" can also avail themselves of these services at subsidized rates. Students will be at liberty to take the test at the nominated test centres with their parents.

This issues with the prior approval of competent authority.

Enel: As above. bv-- rI>llb

DEO (School)

All Heads of Govt. Schools through DEL-E

No.DE.2J(455)1Sch.BLINGOM/ 2'10 Dated- $"J vII (,

Copy to:- I.PS to Secretary (Education) 2.PS to Director (Education) 3.AII DDEs/DEOs for necessary action. 4.0S(IT) to please paste it on the website 5.Guard File

~~\b OSD (School) .' FIITJEE

To Date: 1" February, 2016 The Additional Director - Schools Directorate of Education Old Secretariat, Civil lines New Delhi -110054

(Sub : Request for Outreach in Government sponsored/affiliated schools in New Delhi for "Fortunate 40" - a social initiative of FIITJEE to help & support economically deprived students)

Dear Sir/Ma'm,

Greetings from FIITJEE!!

We are pleased to introduce to you FIITJEE which is guided by the principle "To create world's best for Profit Education company and also world's best Not for Profit Institution that serve the society for thousands of years - may be perennially". With its long standing experience of 23 years, we at FIITJEE consciously work, every moment of the day, to ensure that every student fully unravels his/her multidimensional talent and potential. Keeping this in view FIITJEE launched a scheme in 2008 by the name "FORTUNATE -40" - which is a social responsibility (under its CSR commitment) to help and support economically deprived students.

FORTUNATE 40

Under this scheme 40 students each of Class VIII (going to class IX in 2016) & Class X (going to Class XI in 2016) are supported by FIITJEE by means of classroom coaching and mentoring sessions - aiming for various scholastic & competitive exams like:

• JEE Advanced • JEE Main • All Major State Level/Private Engineering Entrance Exam • Class X & XII Board Exam • National Talent Search Examination (NTSE) • Kishore Vaigyanik Protsahan Yojana (KVPY) • Senior Science Olympaid (Physics/Chemistry/Astronomy/lnformatics) • International Junior Science Olympiad (USO) • Junior Science Talent Search Examination (JSTSE)

FIITJEElimited, 31-32-33 Central Market, West PunJabiBagh,New Delhi-110026. Phone- 011.45634004/05 FIITJEE

Kindly refer to the table below to understand the how a student is expected to set his/her goal and milestone target and subsequently work towards it :

NTSE •

IOfPV > CI." XI & XII

~ Clo-" VIII to XI

Senlo, Sc,",,,,,,, > CI~-" XI & XII ),.,,1...- Olympiad Sci ••nce Olym ••i~d

Middle Segment Senior Segment Students going to IX Students going to XI

The process flow to avail benefit under FORTUNATE -40 is mentioned below:

• Students who are belonging to economically deprived background (ie household income less than 1.2Lakhs per annum) are eligible to apply.

• Once application is processed and accepted by FIITJEE, the student will have to appear for a selection test (scheduled on 7th February, 2016). The selection test is conducted across at the same date and time.

• The results will be declared on 17th February, 2016 (for students of Class VIII - going to Class IX) & 19th February, 2016 (for students of Class X - going to Class XI).

• Selected students will be eligible to join FIITJEE classroom program and avail benefits under Fortunate 40 (upto 100% scholarship on coaching). The general terms is listed in the enclosed Fortunate 40 brochure.

• Non - selected students under FORTUNATE - 40 but who has the potential to do well under proper guidance can join FIITJEE classroom program by paying some fee (which will be less than the actual fee - since substantial scholarship will be offered keeping in mind their financial status). Though there will be no compulSion to join. The students and their parents will be free to take a well informed & conscious decision on this.

FIITJEELimited, 31-32-33 Central Market, West Punjab: Bagh, New Delhi -110026. Phone - 011.45634004/05 FIITJEE

• Enrolment will be offered on the following courses:

a. Class VIII (going to Class IX) - 4 year Classroom program covering all scholastic and competitive exams as listed in Page 1. b. Class X (going to Class XI) - 2 year Classroom program covering all scholastic and competitive exams as listed in Page 1.

• The classes will be conducted at FIITJEE centres in Delhi. For location and address, kindly refer to Annexure 1. Students can select their preferred centre based on their convenience.

• The classes will commence from new academic session ie April, 2016,

• The total selection under FORTUNATE - 40 is listed in the table below

location Total Maximum Selection

FIITJEE - South Delhi Class - VIII (going to Class IX) - 40 students Class - X (going to Class XI)- 40 students

FIITJEE - Punjab! Bagh Class - VIII (going to Class IX) - 40 students Class - X (going to Class XI) - 40 students

FIITJEE- Janakpuri Class - VIII (going to Class IX) - 40 students Class - X (going to Class XI) - 40 students

FIITJEE - Rohini (Kohat) Class - VIII (going to Class IX) -40 students Class - X (going to Class XI) - 40 students

FIITJEE - East Delhi Class - VIII (going to Class IX) - 40 students Class - X (going to Class XI) - 40 students

FIITJEE - Dwarka Class - VIII (going to Class IX) - 40 students Class - X (going to Class XI) - 40 students

Total Maximum Selection/Seats Available in Delhi-

Class VIII (going to Class IX) - 240

Class X (going to Class XI) - 240

FIITJEElimited, 31-32-33Central Market. West PunjabiBagh,New Delhi llOOZ6. Phone 011.45634004/05 FIITJEE

Information Related to FORTUNATE - 40 Selection Test

• Test Date - ]Ill February, 2016 (SUN DAY)

• Last date for application - 5th February, 2016

• Test will be conducted at FIITJEE nominated test centres. Please refer to Page No 3 of (Information Booklet enclosed)

• Application forms available from FIITJEEcentre at NO COST. The same can be distributed to schools as per request.

• Students will have to select preferred study centre and test centre at the time of filling up of the application form. (Please refer to centre code and test centre code in the Information Booklet enclosed)

• At the time of filling up the application form certain basic documentation is mandatory. Guidelines are listed in a "Self Declaration Form" to filled and signed by the parents/guardian of a student.

• For test timing - please refer to Page No 1 of FORTUNATE 40 (Brochure)

• For test syllabus- please refer to Page No 7 of FORTUNATE 40 (Brochure)

• For general terms and conditions - please refer to Page No 8 of FORTUNATE 40 (Brochure)

• The last date for enrolment and availing FORTUNATE 40 benefits will be notified to the students at the time declaration of results.

• Enclosed following documents for your reference:

a. Course Booklet b. Performance of our Students in various scholastic & competitive exam c. FIITJEEclassroom program benefits d. Reward booklet - If a student brings name and fame to the country at International stage and/or if they secure top ranks they are entitled for rewards by FIITJEE.

In order to take this opportunity to large number of beneficiaries in Delhi, we wish to request and sought your kind support so that the information and benefits of FORTUNATE 40 could be made available to all those students who are otherwise forced to quit their dream owing to financial constraint.

We look forwa~~tG~Iii"ar:f-rQQ1.you. Thanking you in anticipation. / ,12.1= L/, ~-,"",'\ ,,0, f ...:: ' •.• -. :~I \Nest. \, r~,- , ..~ p..,"CIIIJ'~~?2..\ \. ~-l- . P"~ alda'i' ,,~I",\",~., I ;:, -1(.>.1 7\,,' ''"' '.~: .•, rue ctor-~~ emi~ :::;>:(1',1 .!'/ »: PI :. ,",\1'" /", FIITJEELtd 1-31;'3.?-~llentr91 Market, West Punjab! Bagh I New Delhi -110026 E ..partho.haldar'@fi~'§"ib~ '-'-::-:--:-- --~

NB : All for communication and coordination we will nominate company representatives to ensure smooth coordination. For the time being Mr. Samiran Datta, CEO (M:9910330466/E : [email protected])will be coordinating with your office.

FIITJEELimited, 31-32-33 Central Market. WestPunjabi Bagh, New Delhi 110026. Phone 011.45634004/05 FIITJEE

Annexure - 1

FIITJEE centres in Delhi

Location Address

FIITJEE - South Delhi FIITJEE House, 29 - A, Kalu Sarai, Near Metro Station, Sarvapriya vthar. New Delhi -110016

FIITJEE - Punjabi Bagh 31,32,33 Central Market, West Punjab! Bagh, New Delhi -110026

FIITJEE- Janakpuri 8-1, 623 2,,,1 Floor, At Distt Centre Crossing, Opp Metro Pillar No 574, Janak Puri, New Delhi -110058

FIITJEE - Rohini (Kohat) 367, Kohat Enclave, 2nd & 3rd Floor, Near Kohat Metro Station, Pitam Pur a, New Delhi - 110034

FIITJEE- East Delhi sth Floor, Roots Tower, Dtstt Centre, Laxrni Nagar (Near Nirman Vihar Metro Station), New Delhi -110092

FIITJEE- Dwarka Plot No 47, (Opp Sal Bhawan International School), Sector -12B, Dwarka, New Delhi.

For complete details in terms of location, phone numbers etc, kindly refer to Page No 14 of Fortunate - 40 (Brochure) enclosed along with this letter.

FIITJEELimited, 31-32-33Central Market, West Punjab Bagh.New Delhi-110026. Phone 011.45634004/05 FIITJEE

~, Information~~~_w=-,,~,,_,~.Booklet__ ·~~·_, ~#

FORTUNATE 40

A Social Initiative by FIITJEEto Help the Economically Deprived

Your dream will not just be a dream! Breaking Financial Barriers, FIITJEEpromises to help you realise your dream.

Selection Test: Sunday 7th February, 2016

For Students presently in

Class VIII (soon going to Class IX) i.e. Aspirants of JEEAdvanced, 2020 and

Class X (soon going to ClassXI) i.e. Aspirants of JEEAdvanced, 2018

A Program to provide worfd-Ctass training to serious Students from financially weaker backgrounds to achieve their goal of Success & Top Ranks in JEE Advanced and Other Competitive Exams. Eligibility For Students presently in Class VIII (soon going to Class IX) i.e. Aspirants of JEEAdvanced, 2020and For Students presently in Class X (soon going to dass XI) i.e. Aspirants of JEE Advanced, 2018

Student should be from Central Government School, State Government School for under privileged section of satiety for example students studying in Navodaya Vidyalaya Samiti Schools. The total parental income should be less than Rs. 10,OCIOf- per month. Other students (studying in public f private schools) may also apply, however their application will be considered on case to case basis and on the discretion of the management.

Last Date to Register Thursday, 4th February, 2016

Result Declaration Dates For Students presently in Class VIII (soon going to Class IX): Wednesday, 17th February 2016 For Students presently in Class X (soon going to Class XI) Friday, 19th February 2016 Results will be Available at www.fiitjee.comandwww.fiitjee.wm/f40.htm

How to Register Fill in your complete details in the Application Form mentioning test centre, segment code and preference of study centre alongwith: (a) Self Declaration Form (of parental income) (b) Two passport size colour photographs and submit it to the nearest FlITJEE centre. Registration is OPEN at all FIITJEE Centres. (for complete list of FIITJEEcentres, see page no. 14 to 16 of Fortunate - 40 Brochure)

Documents Required to be submitted at the time of Admission: Selected Students will have to submit the following documents at the time of taking admission: 1. Marksheet of last class attended 2. Certificates of scholastic achievements (if any) 3. Residence proof (Ration card / Aadhaar Card I Passport / Election Id Card of parents) 4. Income proof of parents (Father & Mother) as given below: (a) Salary Slip of last month (if employed in a private firm / Government I Semi Government organisations) (b) Affidavit f self declaration form (as per requisite format) duly attested by anyone of the following - 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) I Assistant Commissioner & Above Rank. In case you are not able to get desired co-operation from these officials you may then approach Chief Minister, Home Minister or Education Minister for the State, 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 or even Honorable President or Prime Minister.

Fee for Selection Test Nil

Test Schedule & Pattern

For Students presentlv in C/ou VIII (soon going to C/au/X) Paper 1(3 hours) Objective Type Questions to gauge current level of preparedness (10, Science & Mathematics) 9:00 am . 12:30 prn

Paper 2 (3 hours) Objective Type Questions to test Goal oriented Analytical Skills

(Physics, Chemistry & Mathematics) 1:30 pm - 4:45 pm

For Students Pfesently in Class X (soon going to Class XI) Paper 1 (3 hours) Objective Type Questions to gauge current level of preparedness (10, Physics, Chemistry & Mathematics) 9:00 am - 12:30 pm

Paper 2 (3 hours) Objective Type Questions to test Goal oriented Analytical Skills

(Physics, Chemistry & Mathematics) 1:30 pm - 4:45 pm

Note: The time period of 9:00 am to 9:30 am & 1:30 pm to 1:4S pm is for filling up the information on the OMR Answer Sheet and for reading the examination instructions. For information on how to fill up Answer OMR Sheet, please download" An Introduction on OMR Sheets" from www.fiitjee.com/fillomr.pdf

Details of Segment, Registration Centres, Study Centres & Test Centres with CODES

1. Segment & Segment Codes {to be filled in point no 2 (c) of the Application Form]:

Segment Segment Code

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

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

2 2 Registration Centre I Study Centre Codes {to be filled in Point No 2 (b) & 2 (d) of Bar-coded Application Form}'

AV

3 Test Centre Codes {to be filled in Point No 2 (e) of Bar-coded Application Form]:

Test Centre Test Centres Code 290 Allahabad - FIITJEE Ltd, 9 A, Edmonston Road, Opp. NIP, Civil Lines 170 Amritsar - FIITJEE Ltd., 3rd Floor, SCO - 31, District Shopping Centre, a-arock, Ranjit Avenue 550 Barlgalore - FIITJH Ltd" 113/114, 3rd Floor. HTR Ch~mber" S.C, Rd, Opp. HOY,Jla Hotel, Seshadrlpuram 648 Bangalore - FIITJEE Ltd" 11'19,S S Plaza, 13th Cross, Sth Sector, Outer Ring Road, HSR Layout 551 Bangalore - Saint Joseph lndlan High School, Near Mallya Hospital. Vittal Mallva Road 462 Bhilai - MGM S~hool, Sector - 6 470 Bhopal- FIITJEE Ltd" Plot No 102, Back Lane of City Hospital, Zone II, M.P. Nagar 730 anueeneswer - FIITJEE Ltd" Bharat Scouts & Guides Complex, Scouts Bhawan, 2nd Floor, C- IX / 8, Unit - 3, Bhubaneswar 822 Bhubaneswar - kasturtba Shlkshvashar arn. Plot No: 695, Opp. Nebar d, Navapalli 848 Bok~ro - Sardar Patel Public School, Sec-9/A, BRoad Bokaro Steel City 162 Chandigarh - Shivallk Public School, Sector 41 623 Cherlrlai (Adyar) - Kumararani Meena Muthaih Mat Hr. Sec School, Gandhi Nagar, Adyar 611 Chennai {KilpaukJ - Maharishi vrcve Mandir Senior. Secondary. School, No. 28, Dr. Gursamy Road. Chetpet 613 Chenrlai {Sriperumbudurj - Maharishi International Residential School, Santh<3velur, Sunguvar Chathlram 637 Cherlrla; Ivetasaravakkamj - Devi Academy Senior Secondary School, Plot No, l/E-l, Door No.7, Alapakkarn Road 676 Coimb

199 Delhi NCR (Faridabad) - Gita Convent School, Sector 16, Faridabad 200 Delhi NCR (Ghaziabad) - FIITJEE Ltd" Inspiration Plaza, Plot 0-6 & 7, Raj Nagar District Centre (RDC) 304 Delhi NCR (Greater Noida) - Pragvan School, Sector-Gamma-I,Greater Nelda

3 - Test Centre Test Centr Code , , " " 182 Deihl NCR (Gurgaon) - Blue Bells Model School, Sector-"---. , 211 Delhi NCR {Noida}- Lord Mahavira School, Sector - 29, Naida 840 Dhanbad - FIITJEE Ltd., Tara Apartment, Plot No 2311-2313, Moma Saraidhela, Dhanbad 740 Durg~pur - FIITJEEltd., A·3, Nandalal 6ithi, City Centre 92O Gorakhpur - FIITJEELtd" Araji, No 18, Prabha Complex, Main Kasva Road 930 I Gwalior - FIITJEELtd_. Rama Plaza, 12-C, Kailash Vihar, City Centre 520 I Hyderabad (DiI5ukhnag~r) - FIITJEELtd" D,No .. 16-11-477/612/2, Opp: S~shi Hospital 530 Hyderabad (Kukatpally) - FIITJEELtd., H.No.12-97, Plot No.1, Opp Pat~unta Huda Park, vuavnager 510 Hyderabad (Saifabad)- FIITJEELtd., U 5·9-14/6, Opp. Secretariat ~80 Indore - FIITJEELtd., 27, 2nd Floor, Scheme 54, Opp. Orbit Mall, PU-3 Cornmenc al Bhamori, AB Road 270 iJ3ipu~- FliTJEE JLN Campus- 3 AI D.LTower, J.L.N. Marg, Jaipur 320 Jaipur - fllTJEE Ltd., First Floor, C-1 C Block, Vaibhav Multiplex. Amrilpa~ircle, vetshan Nagar m Jaipur - fllTJEE ltd., vfovadhar Nagar, 302, 3rd Floor, Times Square, Central Spine. Vidyadhar Nagar Kanpur - FIITJEELtd" 16/116 Karmin Arcade, Civil Lines 240 - ._----- 664 Kochl - Saraswathl Vldy;lnlketh~n P~b~c School, Peranoccr Road, Elama~.~aril. Kochi 711 I Kolkata -J.1. Ajmera School. 12B Hetshvam Road 356 I KoIk••t {Ultan danga ) - Sl Francrs Xavrer SCh00,I GA Block Purbanchal Phase I Sector III Salt Lake City 220 Lucknow - FIITJEELtd.. The S(holars Home School. vipul Khand - 3, Gomti Nagar 248 Lucknow -M.G. Convent School. Sector - G, l.DA Colony. xenour Road, Near Power House Chauraha, Aashiana 600 Meerut - FIITJEELtd.. Property No 80 Behind, Sales Tax Office, Mangal Pandey Nagar, University Road 420 Mumbai {Andheri) - FIITJEELtd" Baba House, Ground Floor, Andheri curta Road, Off Western Express High Way. Andhe!i East 430 I Mumbai {Chembur) - FIITJEEuo.; Ujagar Complex, Opp. oeoner Bus Depot, Off Sian Trombay Road, Deonar. Chembur 440 MumbaiJKandiveli) - FIITJEELtd." T~akur Vidya Mandir, Thakur Complex. Kilndivali {EI 450 Mumbai [Navl Mumbai) - FIITJEELtd.., 8-500, 2nd Floor, Vashi Plaza, Plot No 80-81. Sector-17. Navi Mumbai 400 Mumbai {Thane) - FIITJEELtd, Evershine Mall, 2nd Floor, Shivaji Path. Opp M.H. ~igh School. Near Station Road, Thane [West) 817 MutaHarpur - North Point Childrens High School. Sherpur Road, Mithanpura Chowk, P,0, Ramna Nagpur· FIITJEETower, 210, Opp. Children's Traffic Park, Oh~rampe_'_h__ 490 - 492 Nagpur - Science Club, Raut Wadi, Akola ------patna - patna St. Michaels School, Ashok NJgJr Road No-3, Near Dwarka College Kankarbagh 760 - ~ P~tna - Model St. Michel High School, Dujar a, Buddha Colony 814 --- - 339 Pune - Bharati Vidyapeeth English School. OpP. Balewadi Sports Complex. Near MOle Engineering (oll~ge, Balewadl 390 Pune - FIITJH Ltd., 3rd Floor, Vega (entre, Swargale, Shankar-sheth Road, Gultekadi, Pune 380 Raipur - Shankar Nagar Vidya Mandir School, Near vrovc Hospital, Shankar Nagar I 989 Ranchi - Ranchi - st. Aloysius School, Purulia Road ~ 230 Shaktinagar_NTPC - FiiTJEELtd" Employee Development centre, Hostel NO.-3, NTPC, Dist. Sonebhadra 911 Vadodara - Alembic Vidyalaya. Gorwa Road Vadodaro -- ~ 1 250 Varanasi - FIITJEELtd.. B-38/1K. Mahmoorganj. Varanasi 580 Vijayawada - FIITJEELimited, 38-8-45.{Pas>port Office Building), Opp.Alllndia Radio Station, M,G Road 568 Visakhapatnam - FIITJEEltd. {Extn,I, Plot No. 30-C, 5th Lane, Dwarakilnagar, Visakhapatnam

Terms & Conditions of FORTUNATE 40 (2016)

1. Fee Waivers for FIITJEEPrograms and Hostel Fee Waivers will be decided on the ba5i~ of combined performance in both Paper 1 & Paper 2, Performance in Paper 2 will be considered only for those Stude~ts who qualify (i.e. clear minimum cut-off marks) in Paper 1. Students must appear in both the Papers i.e, Paper 1 & Paper 2 to become eligible for any Program Fee Waivers I Hostel Fee waivers 2 The final discretion of awarding the fee waivers far FIITJEEprograms & hostel fee waivers in each cas~ will remain with FIITJEEmilnagement and thi~ decision will be final and binding on the (andid"te. 3, Fee waivers for FIITJH programs & Hostel Fee Woivers are vdlid lor the ~ele(t mentioned programs only. Students enrolling with benefits (Scholarship for fllTJEE Program I Hostel Fee Waiver) associated with Fortunate 40 selection test. cannot join anv other institute in any form. In case the Student joins another institute. all the benefits given will be withdrawn and FIITJEEcan also take action against such ShJcient 4. Hostel fee co"ces~io", Iii ~ny) ~re valid only lor FIITJH's associate hostels I lodging & boording facilities (wherever available & for mole Students only) made available through fllTJEE, subj~ct ta the Student joining that particular hostel and availability of seats. The concessio~ will be given monthly betwee~ April. 2016 to March, 2020 for joining Four Year Classroom II~tegrated School Program for JEEAdvo~ced, 2020 OR between April, 2016 to March, 2018 for joining Two Year integr"ted School / CIJssroom Program lor JEEAdva~ced, 2018 and only for the duration of Integrated School I Classroom program. The Hostel fee concessions (il any) are valid lor the above mentioned progroms only, The hostel fee con(essions {if a~y) will b~ p,,;d directly to the hostel owner by FIITJEE,Hostel fee ccncesstcns lif any) is for a

National Admissions Office: FIITJEE House, 29-A, Kalu Sarai, Sarvapnva vrhar. New Delhi -110016 Ph: 011-49283471/73/75 All India Toll Free No.: 1800 114242 E-mail: [email protected] Web: www.fiitjee.com 4 Self Declaration Form of Total Parental Income for Students registering to appear in FORTUNATE 40 Selection Test on 7th February, 2016 ••

We ...... (Father) & ...... (Mother), the parents of ...... (Name of Student) who will be appearing in Fortunate - 40 Selection Test to be held on 7th February, 2016, hereby declares

that our joint income is Rs . (In words Rupees ...... )

per month.

If at any stage, it is found that the above information given by us is false I not true, all the benefits given to our ward, attached with Fortunate - 40 Selection Test to be held on 7th February, 2016, will be withdrawn and legal action as deemed fit, may be taken against us and our ward.

Documents Required' Selected students will have to submit the following documents at the time of (AII/Je time of Admission) taking admission

1. Marksheet of last class attended I I 2. Certificates of scholastic achievements (if any) 3. Residence proof (Ration card I Aadhaar Card I Passport I Election Id Card of parents) 4. Income proof of parents (Father & Mother) as given below: (a). Salary Slip of last month (if employed in a private firm I Government I Semi Government organisations) (b). Affidavit I self declaration form (as per requisite format) duly attested by anyone of the following - District Police Chief (City Chief in case of Metro), General Manager or above rank of Nationalised Bank, District I Income Tax Chief (City Chief in case of Metro) I Assistant Commissioner & Above Rank. In case you are not able to get desired co-operation from

I these officials you may then approach Chief Minister, Home Minister or Education Minister for the State, Minister of Home, Minister of Foreign Affairs, Minister of Education at the Centre, Supreme Court & High Court I, Judge, Cabinet Secretary, Home Secretary, Foreign Secretary, Education Secretary at the Centre or even Honorable President or Prime Minister.

We have received & read the Tenns & Conditions printed in the Information Booklet & Brochure of FORTUNATE 40 to be held on 7th February, 2016 & agree to abide by the same.

Date: (Name of Father) (Signature of Father)

Place: (Name of Mother) (Signature of Mother)

Mobile No.: (Father) (Mother) I Registration No. of Student: (for Official use only) ==-=- FIITJEE APPLICATION FORM

(for Official use only) ReglslretionNo. Allolled: _

Form Ched

Please fill this Form with a Black I Blue pen in BLOCK Letters only Apphcation Form No. F ~ 19 5 3 5

Are you already Enrolled I Registered in FliT JEE ? IIyes. please provide the following info below

a] Enrollment Number Registration Number

b) Students ID __ Mobile Number (DO NOT STAPLI::.)

1. Details about the Student: a) Name 01 the Student __

b) Date of Birth _ (DD/MMIYYYY) (e) Gender (.r) Male Female

c) Last Annual Exam IBoard Exam Aggregate Marks (%) (f) Nationality pnctoq- rph f r Ha I I k d) Stream you will pursue after Class XII {Please tick (./ I} Engineering [ J Non·Engineenng: Humanities Fundamental Science ~ Commerce Medical L-J If other, plene specify

2. ueteus to be fitted in {for Registration Centre. Study Centre. Test Centre & Segment Codes. please refer to POint no 1 2 & J )f relevant Information Booklet):

(a) Test Date (b) Reqrstranon Centre Code (c) Segment Code (d) Study Centre Code L (e) Test Centre Code

1ft Class' Presently Studying In the Current Acsoermc Year (AY) ~ • (10, Clns 5//, fill 05, Class 6!h fill 00, Clus 7th fill OT, Class Ith fill 01, Clns 9th fiN OSI, Class 10th fill 10. Clus Il1h IiI/H, Class 12th fi/I 12 & Class 12th Pass lil/ll)

(g) How do you want to receive the Hall Ticket '------'E-Mail Prmted

(Printed Hall rlClcets will be Issued only if fhls Application Form Is submitted to. FIITJEE office in pel'SOn.,

J. Communication Details: (8) E·MailIDs and Mobile Nos.

E-Mail tD (Please Fill In BLOCK Leiters Only) MObil. Number Student

Father

Mother

Whal is your preferrede-mail ID Student Father Mother What IS your preferredMOblteNo. St~dent Father L.. Mother

(b) Correspondence Address: (c) Permanent Address: (Pleese men/ron only" differenl from Correspondence Address) (Pleese do nol wnle 'lour (your Fe(he,'s name in eese addross boKes Fill/he eoaress only will •••, (hll spacli proVided in boxeS.)

4. Details about the SChool Presently Studying in/ Last Attended:

(a) School Name & Address

C!ly I Town

Pin Code State Tel No (b) Board (SchOOlS affiliated to) {e} Your Current I Last Class Rank In your scncor

(d) Name of your School Principat

(e) Name of your Subject Teacher Mathematics Physics

Biology Chemistry --=-=-=- ----=-==- -ee ::: :::- -=-= =-

S. Details about Parents (in BLOCK Letters only)

Father's I Legal Guardian Name __

Occupation _ Desiqnation ~_ Qualification

Office Name I Address ContactNos _

Mother's Name

Qualification ____ Occupation Oesiqnauon

Office Name I Address

___ Contact Nos

6. Oelails of your Scholastic Achievements in any of Ihese exams (Please tick (,t') & give its details)) ~ SAT NTSE ~ JSTSE NSEJS MTSE,------, KVPY Olympiads C U

Oetails_

7_ Are you taking any specialized Coaching for Competitive Exams (Please tick( •.•..)} y~ No Since (Year)

If Yes, Name of your Coaching Institute

Your Overall Rank m your Coaching Institute _

8. Details about Your Sibling:

Name 1 (Brother I Sister) Class presenlly studying In

Name 2 (Brother f Sister) Class presently studying In _

9. How did you come to know about FIITJEE Programs? {Please tick("",}}:

Newspaper Advt. Social Media News Paper Insert Banner! Poster Website E- Mailer

Hoardings Radio Present! Ex- FIITJEE Student Friends I Relatives Through FIITJEE Faculty

if other source (please SpeCify)

Declaration by the Student I Parent f Guardian

• I'we have received 8.read the Terms 8.Concrnons printed in the Informal ion booklet of the Test Dale mentioned against Point No 2 (a)ofthisApphcation Form and promisa to abIde by the same • I have also cross verified the COdes filled in above Point 2 and I understand if an error occurs in tho recrstrancn due to wrong codes it will not be corrected by FliT JEE • Tesl Dale, Test ceeue ccoe. Program Code etc. cannot be Changedoncereglstered. • RegoSlri1lion Fee will nol be refunded In any case of transferred to any ceer Admission Test Date • Iau1honze FliT JEE to contact and send commurllCallon/,nformation by $MS, e-ma~. poston 1he above men1ioned communication detallsglwn by me • tn case a stccem reappears III FliT JEE rest. hIS' her scholarshIp (if awarded} will be scaled down by one slab so that he, she does nol haw any undue advantage over fresh appearing Sludents • FliT JEE reserves the right to offer study centre other Ihan the one opted by student. subject to availability! constraints of seats. • Once students is granted admission to the hostel, he will not be permitted to withdraw during the course of the ecadornic session and not refund will be made during rmc- session • Once a student JOInsthe study centre offered (Irrespechve of his I her choICe of study centre opted before JOining). no request for Change of sludy centre WIll be enterteoec. nor the course fee paid WI" be refunded under any cm::umstances • FnT JEE reserves !he righl to change I cancel any Program. Tesl Dale. Test Centre. Study Centre. el.g,blhty crnenon 8. CotJrse Fee wrthouI pnor notice. • The Reglslered OffICe of FliT JEE llm~ed IS at New Dethl. In case of dIspute. students I parents are subject 10the exclusrve Junsdidion of appropriate courts In DeIhl f New Deihl only All dlspo;ted shall be referred to the Sole Atbl!ralor apPOInted by the Management of FliT JEE limited The decision of the ermtraior shall be final & binding The arbitrator so apPOInted shall not be incapaCitated for reasons of their beIng the employee of FliT JEE lImited or its sister concern and for reasons of having any prior linkage whhtne company

Fee Pard as. In Cash f DD I Pay Order No.· __ ueteo Bank

II we hereby declare thai the mrcrmauon furnished on this Application Form is COfTe<:\ [0 the best of my knowledge and belief.

Date: (Signlltufll of Student) (Name of Student)

Place: (Signature of Parent I Guardian) (Name of Parent I Guardian)

National Admissions Office: FliT JEE House, 29-A, Kalu Sarai, Sarvapriya Vihar. New Delhi - 110016. Ph.: 011-49283471173175 All India Toll Free No.: 1800 11 4242 Web: www.fiitjee.com =-=-=- -::::.-::::.= ------.••...•.- FIITJEE APPLICATION FORM

(for Offici.t use only) Registrntion No AIIottecI: _

Form Checked by: Employee Code: Sognaturu: Date:

Please fill this Form with a Black I Blue pen in BLOCK letters only Application Form No. F 1034784 ---- Are you already Enrolled I Registered in FIITJEE 7 If yes, please provide the following info below:

a) Enrollment Number Registration Number _

b} Students 10 Mobile Number _ (00 NOT STAPLE)

1. Details about the Student: Paste your a) Name of the Student _ recent passport size color photograph here b) Date alBirth (DDIMMIYYYY) Ie} Gender (.r) Male D Female 0

c) last Annual Exam I Board Exam Aggregate Marks (%) _ (r) Nationality __ Carry one aoornonat photograph for Hall Ticket d) Stream you will pursue after Class XII {Please tick (y"')}:

Engineering ~

Non-Engineering: Humanities D Fundamental Science D Commerce MedicaiD II other, please speclfy _

2. Details to be filled in (for RegIstration Centre. Study Centre, Test Centre & Segment Codes, please refer to point no. 1, 2 & 3 of relevant Information Booklet):

(.) Test Date DC =r:JITI::= (b) Reqrstration Centre Code ~~ (c) Segment Code =:JCC= (d) Study Centre Code '--" (e) Test Centre Code DL., (I) cress: Presently Studying in the Current Academic Year (AY) DO • (fo. Clus 5fh fill 1)5,CI;>ss61h fill1)6,CI.u 71hfill07, Clus Blh fill06. Clus Ihh fill tit. C/us 1Chh fill Ia. Cia" 11th ml11, C/us 12th ml 12& Ct..ss 12th Pus mill).

(g) How do you want to receive the Hall Ticket [J E-Mail ~ Printed (Printed Hall Tickets will be Issued only If this Application Form Is submltflld fO a FIITJEE offlce in person.)

3. Communication Details: (a) E-Mail IDs and Mobile Nos.

E_Mail10 (Please FiII;1l BLOCK Letters Only), _ Mobile Number

Studellt

father

Mother

What ISyour preferred e-mail10 0 Student Cfather -' Motller What ISyour preferredMobileNo. 0 Student ~ Father 0 Malhe.

(b) Correspondence Address: (c) Permanent Address: (Please mention oo1y ff different from Correspondenre Address) (Please do not write your /your Fa/her's name In these address ecses. Fill the address only WIth,,, the space protIIded in boJ(es.) ------'\ r

Pin _ ------/ l------~:======:p:'"~======- _ 4. Details about the School Presently Studying in I Last Attended:

(a) Scncot Name & Address

__ City ITown

-- Pin Code Stale _ Tel. No.

(b) Board (School is affiliated to) (c) Your Current I Last Class Rank in your School

(d) Name of your School Principal

(e) Name 01 your Subject Teacher: Mathematics _ Physics

Biology Chemistry _ ~-~--- -•....• -...,:;;;;--~------

5 Details about Parents (in BLOCK Letters only)

Father's I Legal Guardian Name ~~~_

Occupancn _ Qualification ~~~~~~~~~~_

Office Name I Address ContactNos_~~~~~~~~~~~~~~~~~~~~~_

Mother's Name _

Qualification Occupation _ Designation

Office Name I Address

___ Contact Nos

6. Details of your Scholastic AChievements in any of these exams {Please tick (.I') & give ils details)}:

KVPY --, NTSE JSTSE NSEJSLJ MTSE --' Olympiads SAT ::J Others =:J Details

7. Are you taking any specialized Coaching for Competitive EXCIms (Please tick( •••.)} No ~ Since (Year)

If Yes, Name of your Coaching Institute

Your Overall Rank in your Coaching Institute ~~~~~~

8. Details about Your Sibling:

Name 1 (Brother I Sisler) Class presently studying in

Name 2 (Brother I Sisler) Class presently studying in

9 How did you come to know about FliT JEE Programs? (Please tick(,,)}

Newspaper Advt. Social Media News Paper Insert Banner J Poster Website E- Mailer

Hoardings Radio Present' Ex- FliT JEE Student Friends , Relatives Through FliT JEE Faculty

if other source (pleasespecify),~~~_

Declaration by the Student I Parenti Guardian

• II we ilave received & read the Terms & Conditions printed in the information booklet of the Test Date mentioned agai~st Point NO.2 (a) of this Application Form and promise 10 abide by the same • I have also cross verified the Codes lilled in above Paint 2 and I understand if an error occurs In the registmtlon due to wronq codes it will not be corrected by FliT JEE. • Test Dale. resrcerure Code, Program Code etc. cannot be changed oocereeetereo. • RegIstratIon Fee will not be refunded In any case Oltransferred to aJlY other AdmISSion Test Date • I authonze FtlT JEE to contact and send commumceuce r IIll0rmation by SMS, e-mail, post on the above mentioned oommulllcat.oon details gIven by me • In case a student reappears Ir\ FliT JEE Test. his I her scholarshIp (If awarded) will be scaled down by one slab SOthat he I she ooes not have any undue advantage OIIef fresh appeamlQstudents • FliT JEE reserves the nght to oHer study centre other Il\anlhe one opted by 51udem, subject to avaIlabilIty Iconstraims 01seats. • Once students IS granted adm,ss.on to the hostel. he will not be permItted to WIthdraw dunng the course of the eceeermc session and not refund WIll be made dunng mld- session • Once a student JOInsthe study centre oltered (IrTespective 01hiS I her enoree 01study centre opted before joining), no request lor change 01study centre will be entertained, nor the course tee paid WIll be relunded under anyc"cum6t~nces. • FliT JEE reserves the right to change I cancel any Program, Test Date. Test Centre, Study Centre. eligibility cntencn & Course Fee without prior notice. • The Registered Office of FliT JEE LImited is at New Delhi. In case 01dispute, students I parents are subject to the exclusive junsdiction 01appropriate courts In Delhi I New Deihl only All dIsputed snerce rererred to the Sole ArbItrator appcmree by the Management of FIITJEE LImited The cececn of the arbItrator shall be final & bindIng The arbitrator soappo;nted snau not be jncapacrtaled lor reasons of their being the employee 01FItT JEE LImIted or ItS Slste, concern and for reasons 01haVIng any prior linkage Wlltllhe company

Fee Paid as. III Cash I 00' Pay Order No.: Dated Bank

II we hereby declare that the mfcrrnation tunushec on this Application Form IS correct to the best of my knowledge and belief.

Date: (Signature of Student) (Name of Student)

Place: (Signature of ParentI Guardian) (N.me of ParentI Guardian)

National Admissions Office: FliT JEE House, 29-A, Kalu sera. Sarvapnya vmar. New Deihl - 110016. Ph .. 011-49283471173 f75 All lndta Toll Free No.: 1800 11 4242 Web: WHW.m~ee.com