Paste your recent passport size color photograph here and attach one additional photograph with the application form.

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 : 3. School Name (Presently Attending) : 4. School Address : : Pin: 5. Board (School Affiliated to) : 6. Mobile / Contact No : (i) (ii)

7. E-Mail Address : 8. Class presently Studying In : VIII X 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.

{Please tick ( )}

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.

CENTRE CODE Select the

Registration Centre

Select the Study

Centre* CENTRE

CODE

Select the Registration

Centre

Select the Study 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 besides Sahadeva Reddy Sweets, Dilsukhnagar 520

Hyderabad (Kukatpally) - FIITJEE, H.No.22-97, Plot No.1, Opp. Patel Kunta Huda Park, Vijaynagar Clny 530 Indore - FIITJEE Ltd., 27, 2nd 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:

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 : ____________________

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.

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 _____________________

___________________________________

(Signature of the Student / Parent / Guardian)

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