Instructions for Candidate:-

1. There are 5 sheets in this file.

2. This sheet (Sheet - 1) is to be retained by you carefully.
3. Your Login id is SRIV0605
4. Remember your password and do not disclose it to anyone.
5. Sheet - 2 is the Application Form to be sent by Registered / Speed Post only to IIT MADRAS ZONE
a. Stick your color photo at the designated place.
b. Put your signature at the two designated places.
c. Get the signature of your Parent / Guardian at the designated place.
6. Sheet - 3 is the Application Form and should be retained by you for your reference.
7. Sheet - 5 has three copies of a bank challan (Pay-in slip). Take this to the bank when you pay the application fee.
The bank will retain one copy (Bank Copy) of the challan and return two copies to you.Keep one copy (Candidate
Copy)of the challan for your records and attach the third copy (Institution Copy) with the application.

8. Attach attested copies of Tenth Class/SSLC certificate where your date of birth is mentioned clearly, and all other
applicable certificates (SC/ST/PD/DS/Enlarged Font request).
9. Insert completed Application Form with enclosures (if any) into an A4 size envelope. DO NOT FOLD THE
APPLICATION.
10. Sheet - 4 contains the address of the IIT MADRAS ZONE
to which the application form needs to be posted.
11. Stick the Sheet-4 on top of the A4 size envelope and post it.
12. The packet should reach the corresponding zonal IITs on or before 20th December 2010.

Sheet - 1
 IIT COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B361051664 Zone: IIT MADRAS ZONE Payment Mode: Bank Challan

1. Name of the Candidate as in SRIVATSA SHANMUGAM 17. Name of one Parent / CHANDRIKA VENKATESAN
the 10th Class Certificate Guardian
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling CITY
3. Gender MALE
19. Type of Preparation SELF STUDY
4. Nationality FOREIGN
20. Board of Qualifying CBSE
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 09243433249
Time Number
22. Mother Tongue Tamil
In the above examination did you Not Applicable
obtain qualifying marks? 23. Pincode or Permanent 560076
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Business
7. Sub Category None Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's ONLY ONE PARENT GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 06/05/1994 26. Parent's / Guardian's Total Rs.6,00,000 - 10,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 608 - Bangalore
Cities 617 - Chennai
12. Counselling IIT MADRAS

13. Question Paper Language ENGLISH

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquired is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place:

Date:
Signature of the Candidate
Name of the Parent / CHANDRIKA VENKATESAN
Guardian
Name of the Candidate SRIVATSA SHANMUGAM
Countersigned by Parent / Guardian

14. Address:- F-603, ADARSH RHYTHM APARTMENTS, 15. Photograph

71, PANDURANGA NAGAR,

OFF BANNERGHATTA ROAD,

BANGALORE
Please write
Phone / Mobile 09243433249 your name and
Number application
Pincode 560076 number on the
back of photo
E-Mail Address srivats94@hotmail.com before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B361051664 black ball point pen only (do not sign in capitals)
Send this form along with the necessary documents to IIT MADRAS ZONE

Sheet - 2
 CANDIDATE COPY
APPLICATION FORM FOR JOINT ENTRANCE EXAMINATION - 2011
Application No: B361051664 Zone: IIT MADRAS ZONE Payment Mode: Bank Challan

1. Name of the Candidate as in SRIVATSA SHANMUGAM 17. Name of one Parent / CHANDRIKA VENKATESAN
the 10th Class Certificate Guardian
as in 10th Class Certificate
2. Category General
18. Place of 10th Schooling CITY
3. Gender MALE
19. Type of Preparation SELF STUDY
4. Nationality FOREIGN
20. Board of Qualifying CBSE
5. Year of Passing Qualifying Appearing in 2011
Examination
Examination 10+2
Class or Equivalent For the First 21. Phone / Mobile 09243433249
Time Number
22. Mother Tongue Tamil
In the above examination did you Not Applicable
obtain qualifying marks? 23. Pincode or Permanent 560076
6. Earlier Attempts at JEE NONE Place of Residence
24. Parent's / Guardian's Business
7. Sub Category None Occupation
8. Requirement of Enlarged Font No 25. Parent's / Guardian's ONLY ONE PARENT GRADUATE
Question Papers Educational Background
9. Date of Birth (DD/MM/YYYY) 06/05/1994 26. Parent's / Guardian's Total Rs.6,00,000 - 10,00,000
Annual Income
10. Year of passing 10th Class 2009
or Equivalent
11. Choice of Examination 608 - Bangalore
Cities 617 - Chennai
12. Counselling IIT MADRAS

13. Question Paper Language ENGLISH

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the
Information Brochure and I shall abide by the terms and conditions therein. I also certify that I have not appeared in JEE in 2009 or earlier
and neither taken admission nor paid the registration fee at any of the IITs, IT-BHU or ISM-DHANBAD. In the event of suppression or
distortion of any fact regarding the eligibility criteria, nationality etc., in my application form, I understand that I will be denied the
opportunity to appear in JEE and if already admitted, my admission/degree acquired is liable for cancellation. I also understand that the
decision of the Joint Admission Board regarding my admission to IITs/IT-BHU/ISM-DHANBAD is final and I shall abide by the decision.
Further, if admitted, I promise to abide by the rules and norms of discipline of the Institute I join.

Place:

Date:
Signature of the Candidate
Name of the Parent / CHANDRIKA VENKATESAN
Guardian
Name of the Candidate SRIVATSA SHANMUGAM
Countersigned by Parent / Guardian

14. Address:- F-603, ADARSH RHYTHM APARTMENTS, 15. Photograph

71, PANDURANGA NAGAR,

OFF BANNERGHATTA ROAD,

BANGALORE
Please write
Phone / Mobile 09243433249 your name and
Number application
Pincode 560076 number on the
back of photo
E-Mail Address srivats94@hotmail.com before affixing

16. Signature of the candidate

Signature(within box) in running hand using

B361051664 black ball point pen only (do not sign in capitals)

Sheet - 3
APPLICATION FORM NO B 3 6 1 0 5 1 6 6 4 BY REGISTERED POST/
SPEED POST
FOR Rs. 900 /-

JEE - 2011
Indian Institutes of Technology

Your Choice Choice - I Choice - II

of Cities
for JEE - 2011 608 617

To
From
Name SRIVATSA SHANMUGAM
The Chairman
Address Joint Entrance Examination - 2011
Indian Institute of Technology - IIT MADRAS ZONE
F-603, ADARSH RHYTHM APARTMENTS,

71, PANDURANGA NAGAR, IIT MADRAS

OFF BANNERGHATTA ROAD, CHENNAI

BANGALORE

Pin 5 6 0 0 7 6

Phone/Mobile: 09243433249
Email (if any) : srivats94@hotmail.com Pin 6 0 0 0 3 6

Sheet - 4
PAY IN SLIP BANK COPY PAY IN SLIP INSTITUTION COPY PAY IN SLIP CANDIDATE COPY

REMITTANCE AT ALL BRANCHES OF REMITTANCE AT ALL BRANCHES OF REMITTANCE AT ALL BRANCHES OF

INDIAN BANK INDIAN BANK INDIAN BANK
Paid in to the credit of INDIAN INSTITUTE OF Paid in to the credit of INDIAN INSTITUTE OF Paid in to the credit of INDIAN INSTITUTE OF
TECHNOLOGY (MADRAS) A/C no 906125068 , ADYAR TECHNOLOGY (MADRAS) A/C no 906125068, ADYAR TECHNOLOGY (MADRAS) A/C no 906125068 , ADYAR
BRANCH CHENNAI, BRANCH CODE : 79 BRANCH CHENNAI, BRANCH CODE : 79 BRANCH CHENNAI, BRANCH CODE :79

Name of the Candidate SRIVATSA SHANMUGAM Name of the Candidate SRIVATSA SHANMUGAM Name of the Candidate SRIVATSA SHANMUGAM

Present Address F-603, ADARSH RHYTHM APARTMENTS, 71, Present Address F-603, ADARSH RHYTHM APARTMENTS, 71, Present Address F-603, ADARSH RHYTHM APARTMENTS, 71,
in CAPITAL LETTERS PANDURANGA NAGAR, OFF in CAPITAL LETTERS PANDURANGA NAGAR, O F F in CAPITAL LETTERS PANDURANGA NAGAR, OFF
with Pin Code BANNERGHATTA ROAD, BANGALORE - with Pin Code BANNERGHATTA ROAD, BANGALORE - with Pin Code BANNERGHATTA ROAD, BANGALORE -
560076 560076 560076

Date of Birth 06/05/1994 Date of Birth 06/05/1994 Date of Birth 06/05/1994

Mobile / Landline No: 09243433249 Mobile / Landline No: 09243433249 Mobile / Landline No: 09243433249

E Mail ID srivats94@hotmail.com E Mail ID srivats94@hotmail.com E Mail ID srivats94@hotmail.com

Category : General Category : General Category : General

Amount : Rs. 900 /- Amount : Rs. 900 /- Amount : Rs. 900 /-

Amount in words : Rupees Nine Hundred Only. (*Inclusive of Amount in words : Rupees Nine Hundred Only. (*Inclusive of Amount in words : Rupees Nine Hundred Only. (*Inclusive of
Bank Charge) Bank Charge) Bank Charge)
Name of the Name of the Name of the
Receiving Branch Receiving Branch Receiving Branch

Signature of the candidate Signature of the candidate Signature of the candidate

FOR BANK’S USE FOR BANK’S USE FOR BANK’S USE

Journal No: Branch Journal No: Branch Journal No: Branch

Code Code Code

Application B361051664 Signature Application B361051664 Signature Application B361051664 Signature

Number : of Number : of Number : of
cashier cashier cashier

Branch Date Branch Date Branch Date

Name Name Name

Sheet - 5