Instructor :

Dr. PANDEY

Mobile : 9839101639, 9935031639, 9415712177

IIT        PMT            FOUNDATION           MAIN

ENROLMENT FORM

FULL NAME :



DATE OF BIRTH :        

FATHER'S / GUARDIAN'S NAME :
MAILING ADDRESS :

PHONE NO :                 MOBILE NO :

EDUCATIONAL BACKGROUND
  SCHOOL/BOARD

YEAR

GROSS %

P.C.M.%

TENTATIVE POSITION IN SCHOOL
CLASS Xth          
CLASS XIst          
CLASS XIIth          
After thoroughly considering all my education option and circumstance. I am enrolling in this institute under absolutely no
pressure from the management of this institute. My decision to enrol in this institute is final & under no circumstance, I Can't
claim a refund of the deposited fee. I also hereby agree to abide by the code of descipline and ethics in the institute and
understand that any violation may  result my termination from programme.

DATE .............

Guardian's Signature : ...................................

Student's Signature : ..............

FOR OFFICE USE
DAY : _____________________________________ BATCH : ______________________________________
C CODE :                             
JEE/MEDI. No.