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For Yearlong Classroom Contact Programmes (YCCPs) for Pre-Engineering & Pre-Medical Examinations
APPLICATION FORM
IMPORTANT INSTRUCTIONS: n Please go through the ResoGuide (Information Booklet) & Information Brochure very carefully before filling up the application form. Do take the help of How to fill Application Form mentioned in ResoGuide to fill the Application Form. n Use only Black/ Blue Ball Point/ Gel Pen to complete the Application Form. n Use only CAPITAL LETTERS of English Language to complete the Application Form. n Tick ( ) in the appropriate box wherever double box like this is given.
3. Name of the Applicant: (Leave a box blank between first, middle & last Name) 4. Father's Name: (Leave a box blank between first, middle & last Name) 5. Mother's Name: (Leave a box blank between first, middle & last Name) 6. State of Domicile:
2. Paste your recently taken passport size Colour Photograph (3.5cm X 4.5 cm) by applying gum only. Do not Staple the photo.
7. Date of Birth:
8. Gender:
9. Category:
Jainism
12. Course you are applying for Yearlong Classroom Contact Programmes (YCCPs) :
Target
JEE (Main+Adv) 2017
1. 2. 3. 4. 5. 6.
1. 2. 3. 4. 5. 6. 7. 8.
2. JEE (Main+Adv) 2016 3. JEE (Main+Adv) 2015 4. JEE (Main+Adv) 2015 5. JEE (Main+Adv) 2014 6. JEE (Main+Adv) 2014 7. JEE (Main+Adv) 2014 8. JEE (Main+Adv) 2014
14. Choice of Test Date & Test Centre for ResoNET* - 2013 or ResoMOST#-2013
# [*For JEE (Main+Adv.) Courses only] (Direct Admission for JEE (Main) & NEET (AIPMT) Courses) [ Scholarship Test for NEET Courses only)
English
Hindi
Test Centre
15. Parents Permanent Residence Address (Do not write your or Fathers Name here):
House No./Street: Area/Colony/Village: City/Town/P.O.: Tehsil/Taluka: District : State : PIN Code : Mobile No. (Self): 0 Mobile No. (Parents): 0 Telephone No. (Landline) : 0
(STD Code) (Telephone No.)
Country :
e-mail:
e-mail:
Yes
No
19. Past Performance in Competitive/Talent Examinations (fill the details, only if relevant):
S. No. 1. 2. 3. 4. 5. 6. 7. Competitive/Talent Examination NTSE Olympiads** (P/C/M/B/A/Jr. Sc.) KVPY IIT-JEE / JEE (Main+Advanced) AIPMT / NEET AIEEE / JEE (Main) Other: (____________________) Year (Qualified) Level Qualified (I/II/Final) Max. Marks Marks Obtained % Marks All India Rank (AIR) All State Rank (ASR) Remark (s) (if any)
21. Past Three Years' Academic Performance (including current year) in School/Board Examinations:
Class VII VIII IX X XI XII Address & Phone No. of Class - X School Address & Phone No. of Class - XII School
0 (STD Code) 0 (STD Code) (Telephone No.) (Telephone No.)
City/Town/Village
District
State
Board
22. How did you come to know about Resonance? (In the Source Details, write Newspaper/Magazine/Website's Name, Friend/Relative/Old Student's Name, address & Contact No.)
S.No. 1. 2. 3. 4. Source Old Resonance Students Friends/Relatives Newspaper Resonance Website S.No. 5. 6. 7. 8. Source STaRT 2012 / 2013 Seminar in School/City Other Talent Search Exam Internet/E-mail S.No. 9. 10. 11. 12. Source FM Radio Outdoor/Hoardings Television Canopy/Leaflet S.No. 13. 14. 15. 16. Source Education/Fair Book Magazines Mobile/SMS Any Other Write below the details of source that you have ticked
23. Parents'/Guardian's Bank Account Detail: (any Excess Fee/Refund/Reward/Caution Money amount entitled by the enrolled student shall be deposited by Resonance in this account only)
Account Holder's Name: Account No.: Bank Name: City: Relationship: Branch Name:
Would you like to stay in a HOSTEL managed by Resonance (Applicable to those who are interested to study only at Kota) : Yes
No
DECLARATION
I/We, the undersigned, hereby solemnly and truly declare and affirm that, the information provided by me/us in the application form (as well as the copies of examination forms, qualification documents, etc. as also cheques, demand drafts submitted to the institute, towards payment of course fee) is true and correct. Further, I/We have understood and agree that any misrepresentation or concealment of facts, will justify the denial/ cancellation of undersigned student's admission, or expulsion from the institute at any stage of the Academic Session. I/We acknowledge having read the Terms and Conditions of the application form and ResoGuide & Information Brochure, a copy of which has been duly received by me/us and which forms an Integral part of Admission Packet for admission in the institute for the Academic Session 2013-14, and hereby, irrevocably agree to abide by the same. Further, if the undersigned student is admitted to the institute for the study course applied by him/her, I/We promise to abide by all the rules & regulations and disciplinary norms of the institute as long as undersigned student remains a registered student of RESONANCE. I/We, hereby also declare that while being an enrolled student of Resonance, the undersigned student will be responsible for providing relevant details of all the competitive examinations (in the form of true copies of the application form of the relevant examination) which he/she will be appearing in the future by virtue of coaching & academic support from the institute. Further, I/We, hereby give our free consent to the institute for using the result, photograph & testimonials of the undersigned student, in any form, for its growth strategies and developmental plans, if the undersigned student, succeeds in any of the competitive examinations through coaching and academic support from Resonance at any point of time during the Academic Session 2013-14, and will never have any objection for it.
Signature of one of the Parents/ Guardian : _________________________________ Date: __________________________ If Signed by Guardian,: write his/her Name
Note: In case of any legal disputes, the jurisdiction of court of Kota (Rajasthan) shall be applicable.
Place: ____________________________
Contact No.:
CORPORATE OFFICE: Resonance Eduventures Pvt. Ltd., CG Tower, A-46 & 52, IPIA, Near City Mall, Jhalawar Road, Kota (Raj.)-324005 Reg. Office: J-2, Jawahar Nagar Main Road, Kota (Raj.) - 324005 | Tel. No. : 0744-3012222, 3022222, 3192222 | Fax : 022-39167222, 0744-2427144 Toll Free: 1800-200-2244 | e-mail: contact@resonance.ac.in | Website: www.resonance.ac.in