REGISTRATION FORM

                                     Contact 8083328318, 8271889235,7870537870

ORIGIN JEE CLASSES

[No.1 institute in buxar for preparation for IIT, AIEEE, NEET,Others ,11,12 ,9^th 10^th

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M    Meet us at: Bazar Smiti Road ,  Nai Bazar Road Buxar

      

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REGISTRATION FORM

Registration No.:

(for official use only)

Test Date:                                                                 

Choose Your Test And Study Centre: (Tick Any One)

Programme Options

One-year classroom programme: 2017-18

c JEE MAINS & ADVANCE      c NEET                       c  XI

c     XII                                    c  X                               c IX

Foundation Courses

c  PHYSICS         c  CHEMISTRY  c  MATHS       c  ALL

Batch option: (if applicable) (Write your preference by Marking 1, 2 & 3 )

c Regular                                             c  Weekend                             c  Semi Weekend        

Name:……………………………………                       .D.O.B……. /……./………….

Father’s/Guardian’s name ………………………………………………

Address: House No…………                                            Street..................................

Area .............................................................. City…………………….State………………… …………….Pincode.............................Ph.No................................................Mobile.........................E-mail …………………………………………..

Class studying /passed ……….. ……….Percentage of marks obtained in last exam..............................................

Name and address of the school attending/attended.......... ………………………………………………………………..

How did you come to know about ORIGIN JEE CLASSES ?

[Tick/fill in the appropriate choice(s)]

a)         From advertisement (please specify the newspaper)...............................................................................

b) From posters/banner at................................................................................................................................

c) From present/ex- student:.............................................................................................................................             From posters/banner at.........................................................................................................................

d) Other medium (please specify)......................................................................................................................            

Registration procedure

Submit your application form along with two passport-size colour photographs, a photocopy of the marksheet of your last examination and Rs 100/- as registration fee & Rs 1500/- for Foundation Courses) for  classes  course by cash .

Registration form can be deposited at any of the following centres :

Declaration

I/We hereby declare that all the details stated above in this registration form are true to the best of my/our knowledge and I/we promise to abide by the rules and regulations of the ORIGIN JEE CLASSES

(Signature of Student)                                                                                       (Signature of Parent/Guardian)

Date     :

Place    :