Admission cum Scholarship Test Roll No	

Affix your
recent passport
size photograph
here.

Enrollment No	
To,

Ghaziabad	RANCHI
PATNA

The Managing Director
JEE MANTRA

JEE MANTRA
ADMISSION FORM

Weekdays

Weekends

COURSE APPLIED FOR
Respected Sir,
I want to take Admission in JEE MANTRA. I have read the 'Terms & Conditions' of the Institute mentioned in the prospectus and given overleaf. I agree to abide by the same. My particulars are given below:
(It is compulsory to fill the form clearly in CAPITAL LETTERS only)
First Name 	 Last Name
Father’s/Guardian’s Name 	Occupation 	
(Please specify the post, if in Service)
Mother’s Name 	 Occupation 	
(Please specify the post, if in Service)

Gender	M		F		

*
Date of Birth 	
(DD/MM/YYYY)Blood Group 	 Category * 
(GEN / SC / ST / OBC / PH)

Residence Address
(Permanent Address)
City		State 		Pincode 	
Phone 		Fax 			
			
(STD Code)	(Number)	(Any Other)	(STD Code)	(Number)	

Mobile (Parent's Number) 	Mobile (Student's Number) 	
Mobile (SMS - for communication)* 	 Email-ID 	
Address for Correspondence
(Please ignore if same as Residence Address)
City		State 		Pincode 	
Phone 			Fax 			
				
(STD Code)	(Number)	(Any Other)	(STD Code)	(Number)	
School / College Name & Address				

	% (XII Board, PCB - Aggregate)

CBSE

ICSE/ISC

HS

Any other

Marks Obtained	 % (ICSE Board / Other Board Class X, Sc. & Mathematics - Aggregate)
Grades obtained :	Maths		Science 	 (CBSE Class X)
Signature 

(Attach a Photocopy of Your Original Marksheet)