Admission form

KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP

Application Form
(Target Exam – IITJEE/AIEEE/AIPMT)

Latest
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Course Applying For
Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij
E - 13 E-12 E-11 M-13 M-12 M-11 B-12 B-12 F-10 F-9
PCM PCB

1.Name of the Applicant

2.Father’s Name

Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

3.Mother’s Name

4. State of Domicile

5.Date of Birth
Date Month Year

6.Gender
Male Female

7.Category
General OBC SC ST DS PD

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348

8.Religion

9.Permanent Address

10.Address of Correspondence (All study
materials and test papers will be sent at this
address) with phone/mobile number

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348


11.Medium of Studies to be opted in Kshitij
Education India
Hindi English

12.Past Performance in Competitive/Talent
Examinations, fill if relevalent

S. Competitive Year Level Max Marks % Remarks,
No Or Talent (Qualified) Qualified Marks Obtained Marks (AIR) (ASR) if any
Examination (1/2/Final)

1. NTSE

2. Olympiads

3. KVPY

4. IITJEE

5. AIPMT

6. AIEEE

7. Other

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348


13.Parent’s/Guardian’s Occupation

14.Past four year’s Acadmic Performance
Class Year of Name City/Town/Village District State Board % %
Passing of the Marks/Grade Marks/Grade
Out School Aggregate in PCM/B
12

11

10

9

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348


15. Address and Phone No. of Class 10
School

16.Address and Phone No. of Class 12
School

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348

17.Emergency Mobile No./Email (other
than Parents)
Name Mobile No. Email

18.How did you come to know about Kshitij
Education India? (Write in 30 words)

19.Parents/Guardian’s Bank Account
Detail
Account Relationship Account Bank City Branch
Holder’s with Number
name Student

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348

Declaration
I/We undersigned, hereby assure that the information given in the application form (as well as in all
relevant documents i.e. Cheques, Demand Drafts etc.) is true and correct. I/We have understood and
agreed that my misrepresentation or concealment of facts will justify the denial/cancellation of
undesired student’s admission, or expulsion from the institute at any stage of the academic session.I
have read and hereby provide my/our free consent to the terms and conditions of application form and
mentioned on the website for admission is the institute for the academic session 2012-2013 further, if
undersigned is admitted I/We promise to abide by all the rules and regulations and norms of discipline
of the institute as long as undersigned student remains a registered student of Kshitij Education India.

I/We hereby also declare that while being an enrolled student of Kshitij Education India, undersigned
student will be responsible in terms of providing relevant details of all the competitive examination
(in form of true photocopies of the application form of the relevant examination) while he/she will be
appearing in the future by virtue of coaching and academic support from the institute. If the
undersigned student, as registered student succeeds in any of these competitive examination, Kshitij
Education India will have all the rights of using his/her result, photo graph and testimonials in any
form for its growth strategies and development plans. In such cases I/We never have any objection or
protest for this.

Signature of Student Signature of Parent
Date:- Date:-
Place:- Place:-

Note:- In case of any dispute, the Jurisdiction of the Court of Delhi will be applicable

Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348

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