TARGET: IIT/MBBS, 2015

12, Masilamani Street, T. Nagar, Chennai 600 017.

For Office Use only

Student No:

ENROLMENT FORM
POSTAL SUPPORT PROGRAMME

Affix Passport Size

Photo here

TARGET : IIT / MBBS, 2014 2015

The Principal,

PLEASE ENSURE THAT THIS IS THE COURSE

YOU WISH TO APPLY AND ENROL FOR.

BRILLIANT TUTORIALS PVT. LTD.

COMPLETE BOTH SIDES AND SIGN THIS FORM

WHEREVER NECESSARY.

4.5 4.5 cms

(Enrolment forms
will not be accepted
without the photograph)

Sir,
Have you previously enrolled in any of our courses
Yes

No

If Yes, Course...

Enrolment No.
I am studying in (Name of School, Place)
Exam Board :
CBSE
ICSE
State
Other
Please specify
I am studying in
Class 8
Class 9
Class 10
I will enter Class 9 in

(Month/Year)

I will enter Class 10 in (Month/Year)

REFERENCE NUMBER:

......

I am an NTS Scholar (Attested copy of NCERT Notification Letter enclosed). I am therefore eligible for the Rs. 1000/- Merit
Scholarship.
Please enrol me as a student of your Postal Course for Target: IIT / MBBS (20142015) as marked overleaf.
I herewith remit, the full course fee of Rs. ________
by:
MO/DD drawn in favour of Brilliant Tutorials Pvt. Ltd., payable at Chennai.
MO Receipt / DD No.

Bank

Net Banking/Credit Card/Online Bank Transfer

(Bank routing instructions given below)

Cash/ Credit Card at your Centre in

Date

___
Transaction Confirmation No.

(See overleaf for list of Centres)

Visa

Credit Card Authorization Code

Last 4 Digits of Card No.

*I would like to receive all updates and/or promotional materials as text messages on my cell phone number given below
(Please

Master Card

Date

Yes

No

the appropriate boxes)

I have read and shall abide by the rules and regulations for this Course given in the Online / Hardcopy Prospectus.
Fees once paid will not be refunded or adjusted under any circumstances.
BANK ROUTING DETAILS
All matters are subject to the exclusive jurisdiction of courts in Chennai only.
Pay to: BRILLIANT TUTORIALS PVT LTD.
Yours faithfully,
Signature of Applicant
Date:

Signature of Parent/Guardian
Relationship to applicants

Account No. 0345002100269947

Bank, Branch: PUNJAB NATIONAL BANK LTD,
10, RAJA STREET, CHENNAI, T.NAGAR 600 017.
IFSC Code For NEFT: PUNB0034500
Note: Payment by NEFT only. Bank charges to be paid by student.

(PLEASE PRINT IN BLOCK LETTERS)

APPLICANTS NAME (as in school records) ..:

Date of Birth : Date Month Year .

Sex:

Male

Female

Name of Parent / Guardian :

Permanent Home Address:
Telephone Number:
Fax:

STD Code:
E-Mail: *

Cell Phone: *
PIN CODE:

Name and Full Postal Address to which

all Correspondence and study material
should be despatched:
Telephone Number:
Fax:

STD Code:
E-Mail: *

Cell Phone: *
PIN CODE:

Our course material is in the English Medium only Fees once paid will not be refunded or adjusted under any circumstances.
No instalment facility. Enrolment will not be accepted without the photograph/s. PIN CODE, AN ABSOLUTE MUST. Your application
for admission will not be accepted unless your address is complete with Pin Code. *Denotes mandatory fields.
Brilliant Tutorials reserves the right to use the photographs and/ or testimonials from the student in promotional / publicity material.
REMEMBER TO SEND TWO ADDITIONAL SIGNED PHOTOGRAPHS (preferably colour) WITH THIS FORM
Please keep a copy of this application for your records

Please enrol me in your Target: IIT / MBBS course as marked:

Fees (Inclusive of Service Tax)
Regular

NTS Scholars

Part I for Std 8

Rs. 10,562/-

Part I for Std 8 with Online Test Series

Rs. 13,933/-

Part I for Std 9

Rs. 10,562/-

Rs. 9562/-

Part I for Std 9 with Online Test Series

Rs. 13,933/-

Rs. 12,933/-

Part II for Std 10

Rs. 10,562/-

Rs. 9562/-

Part II for Std 10 with Online Test Series

Rs. 13,933/-

Rs. 12,933/-

Two-year Integrated Course for Stds 9 & 10

(for Students of Std 9 only)

Rs. 16,966/-

Rs. 15,966/-

Two-year Integrated Course for Stds 9 & 10

with One-year (for Std 10) Online Test Series

Rs. 18,427/-

Rs. 17,427/-

Two-year Integrated Course for Stds 9 & 10

with Two-year Online Test Series
(for Students of Std 9 only)

Rs. 22,809/-

Rs. 21,809/-

Signature of Student:

Signature of Parent: