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APPLICATION FORM FOR FIITJEE AWARD

Name of the Student

: __________________________________________________________

FIITJEE Enrolment No.

: __________________________________________________________

Year of passing IIT-JEE

: __________________________________________________________

AIR No.

: __________________________________________________________

Location of the I.I.T.in which studying

: __________________________________________________________

Semester & Year in which studying

: Semester _____________________ Year ________________________

Amount of award admissible per year

: __________________________________________________________

The Year for which award is being claimed

: II / III / IV

Dated :______________

Signature of the Student


Name :- ___________________________________

Permanent Residential Address (in Capital letters) : -

Address

( in Capital Letters) : -

__________________________________________
__________________________________________
__________________________________________
E-mail ID __________________________________

__________________________________________

Phone & Fax (with STD code)__________________

__________________________________________

In case of change in information, please inform us or email at info@fiitjee.com


In case cheque is to be sent at location other than Permanent Residential Address
-----------------------------------------------------------------------------------------------------------------------------------------------------------------

Attestation by IIT Authorities :Certified that Mr. _______________________________ S/o ______________________________________ was studying
in ___________ year of IIT and has passed the same. He has good moral character.

Signature of Authorised Person


Date : _________________

(with seal of the Institute)

----------------------------------------------------------------------------------------------------------------------------------------------------------------FOR OFFICE USE


Passed for payment of Rs.________________
(Rupees________________________________________________)

(Authorised Signatory)

Paid vide Cheque No._______________dated ____________for Rs._______________drawn on Canara Bank, Hauz Khas
Market Branch, New Delhi-110016.

(Sr. Accountant)

(Dy. Manager - Accounts)

___________________________________________________________________________________________________

ICES House, Sarvapriya Vihar (Near Hauz Khas Term.), New Delhi-16, Ph:26515949, 26569493, Fax: 26513942