APPLICATION FORM

This Application Form is also available on our website : www.dlp.allen.ac.in
APPLICATION FORM
Corporate Office
"SANKALP", CP-6, IndraVihar, Kota (Rajasthan)-324005
Trin : +91-744-5162200, 2436001
E-Mail : [email protected]
MAJOR TEST SERIES
Academic Session 2014-15
Center Name
: ________________________________________________________________________
Student Name
: ________________________________________________________________________
Father’s Name
: ________________________________________________________________________
Mother’s Name
: ________________________________________________________________________
Date of Birth
:
Gender (Tick)
: Male
Category (Tick)
: GEN
Postal Address
: ________________________________________________________________________
D
D
M
M
Y
Y
Female
SC
Y
Y
Medium (Tick) : English
ST
EX
FORM No. (for office use only)
PH
OBC
Hindi
Gujrati
Affix here a Recent
SOBC
Passport Size
Color photograph.
Please do not staple.
________________________________________________________________________
__________________________________ City__________________________________
State
: __________________________________ Pin Code _____________________________
Contact No.
: (STD Code)___________________ (Phone No.)_______________________________
Mobile No.(s)
: (1)__________________________________(2)_________________________________
E-mail Address
: (For important updates)___________________________________________________
Previously enrolled
with ALLEN ?
Yes
If yes please
complete
the following
information
No
DEMAND DRAFT DETAILS
Year of Registration in ALLEN
No. : _____________________________
ALLEN Form No.
Dated : ___________________________
FEE STRUCTURE
Course
Code
Total Amount Payable
JEE (Main+Advanced)
6103
` 1600/-
AIPMT+AIIMS
6102
` 2200/-
AIOT JEE(Main+Adv.)
6202
` 300/-
AIPMT
6101
` 1600/-
JEE Main
6104
` 1200/-
AIOT AIPMT+AIIMS
6201
` 300/-
AIOT JEE(Main)
6203
` 300/-
Course
Inclusive Service Tax
Tick ( )
any one
Course
Code
Course
Total Amount Payable
Inclusive Service Tax
Tick ( )
any one
Bank : ___________________________
__________________________________
Amount (in Rs.) : __________________
Amount (in Words) :________________
AIOT=ALL INDIA OPEN TEST
Your JEE-MAIN / AIPMT 2015 Application Form No. :
__________________________________
IMPORTANT :
1. Applicants of course code : 6102, 6103, 6104 need not to register separately for All India Open Test (2014-15).
2. Also attach zerox copy of your JEE-MAIN / AIPMT 2015 Application Form with this form. Failing which your form may not be processed.
3. Gujarati Medium test series JEE (Main) is available only at Gujarat State DLP test centers.
__________________________________
MAJOR TEST SERIES
DECLARATION
I hereby declare,
1. that I have read the instructions of Major Series and I agree to abide by the Rules & Regulations as amended by institute time to time.
2. that I am seeking admission in my own interest and accord.
3. that all information furnished by me in Application Form etc. is correct. I understand that in the event of any information found to be incorrect of
false, my admission may be cancelled without any refund of fee.
4. that I will be responsible for my rustication on behalf of my misconduct / misbehave at test center.
5. that in case of my selection in Medical / Engineering Entrance Exams, the institute reserves the right to use my information for publicity.
Date :
Signature of Candidate
FORM No. (for office use only)

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