Bansal Classes Application Form Reg. No.

p r i v a t e    l i m i t e d All Entries must be filled in capital letters only

A-10, “Gaurav Tower”, Road No.1, IPIA, Kota-324005 Test Centre
1st Preference
(Bull’s Eye / Acme / Nucleus / Sterling)
Course Applied for
(Refer Information Brochure) Test Centre
After qualifying the selection test you wish to take admission at Kota Jaipur Ajmer 2nd Preference

Test Centre for Agra Ahmedabad Ajmer Bhopal Chandigarh Dehradun Delhi
Bull’s Eye & Sterling Jaipur Kolkata Kota Lucknow Mumbai Nagpur Pune Raipur
Test Centre for Acme Kota Jaipur Ajmer Delhi
Test Centre for Nucleus Kota Jaipur Ajmer Affix latest
Note: Center opted must be near to your current Local Address. Test centre once alloted will not be changed.
Passport Size
Colour Photograph
Name:
Date of Birth: D
D / M M /19 Y Y Blood Group Gender: Male Female
Father’s Name:
Father’s Occupation: Designation: Deptt.:
Address:

City PIN Code State
e-mail: Mobile No.:
Tel No. with STD Code: Resi.: Tel. Father’s office:

Name of School with city where studying presently:

Class in which studying as on date:

Are you NTSE qualified: Yes No If yes, upto level

Category: General Reserved If Reserved, please specify
Past academic performance:
Class Name of school Year Board Maths% Science% PCM% Aggr.%
IX NA
X NA
XI NA NA
XII NA NA
Mention the performance of previous competitive examination, if any:

Declaration: I have carefully read the Academic, Administrative & General Rules and Regulations of the Institute as given in the Instruction Manual and agree to abide by the
same. I hereby declare that if I clear the Selection Test and join the institute by paying necessary Fees, I will abide the refund rules of the institute if I withdraw from the course
after the expiry of refund date (as mentioned in Instruction Manual on Point No. 20 & Overleaf of this form). I hereby declare that the information provided by me in the Ap-
plication Form are true and correct to the best of my knowledge. My signature below certifies that i have read, understood and agree to the rules and regulation of the Institute
including those mentioned in Instruction Manual. All disputes are subject to Kota (Rajasthan) Jurisdiction.

Signature (Applicant) with date Signature (Father/Guardian) with date

You are advised to retain a photocopy of the completed Application Form for your records
Enclose:  Photocopy of marksheet for last examinations passed  Admit Card duly completed by the applicant  Envelop duly written candidates address & Course
you are applying for  Acknowledgement card duly filled
Note : For sending above, use the enclosed envelope addressed to us.  Selection Test paper will be in English only, however for Sterling course the Test Paper
will be made available in English & Hindi both.  Although, teaching & Course Material will be in English only.  Test Centre once allotted will not be changed.
 Fee Structure
Course Total Fee 1 Year Basic Course Fee S.T. @10.30% Caution Money Duration
Bull’s Eye 73,350* 66,500 6,850 -Na- Two Year
Acme 73,350* 66,500 6,850 -Na- Two Year
Nucleus 74,901 67,000 6,901 1,000 One Year
Sterling 76,556 68,500 7,056 1,000 One Year
Azusa 47,326 38,000 4,326 1,000 Three Month
Locus 4,412 4,000 412 -Na- As per course
* This course fee is only for first year during studying in class XI; course fee for 2nd year will be announced on 28th Feb. 2011.

 The above course fee does not include Hostel & School Fee.
General Rules
 Fee must be deposited only through Demand Draft or Pay Order. Cash and Cheque (even cheques  Student will attend their classes in
payable at par at all branches in India) won’t be accepted. their own batches; non compliance
 Fee would be deposited in two installments, details of which will be given at the time of result on of this will result into suspension of
website. one week.
 Loss of I-card will cost Rs.500/-
 Sending Fax of the DD won’t reserve your seat; the DD in physical form must reach our office on or
before last date, after the last date the admission would be automatically considered as cancelled.  Change of Study Centre is not
allowed.
 Caution Money of Rs.1000/- is refundable only after student deposit Photocopy of IIT-JEE
Application Form.  If you leave the institute and rejoin,
then 10% of basic fees will be
 If there is any change in rate of Service Tax during the course period the same will be applicable and charged additionally along with
student will bear the same. applicable Service Tax on rejoining.
 Commutation to institute will
Refund Rules be the sole responsibility of the
A. On Application For Selection Test:
student. If any problem occurs
during travelling to the institute
Application Form Fee of Rs. 1000/- is not refundable under any circumstance whether you appear for selection it is solely the responsibility of the
test or not. Those sending the Demand Draft for obtaining Application Form will write their complete and student.
clear postal address with PIN Code to avoid the postal delay.
 If the student indulges in any kind
Students will ensure to appear for the selection test on the centre mentioned on Application Form. If student
misses the selection test for any reason the application form fee will not be refunded. For any discrepancy
of unfair or unsocial activity, it is
before selection test date student will call up our office for clarification.
the responsibility of the students
and his parent only. The institute
B. On Joining our Course: bears no responsibility for the same.
In case you discontinue our course due to some reason or the other, we will refund the fee as per following;
 D re s s Co d e : St u d e nt s a re
no further request will be entertained under any circumstances.
required to wear sober clothes
Course Last Date of Refund Refundable Amount out of first installment (Girls should strictly wear decent
Bull’s Eye 26-04-2010 75% of First Installment of Basic Course Fee (25% will be deducted) salwar suits with dupatta and in
Acme 14-06-2010 75% of First Installment of Basic Course Fee (25% will be deducted) case of non compliance entry
won’t be given in the campus).
Nucleus 12-04-2010 75% of First Installment of Basic Course Fee (25% will be deducted) Male students should wear
Sterling 05-07-2010 75% of First Installment of Basic Course Fee (25% will be deducted) decent shirts with trousers/
pants.
 Date of fee refund is universal even in the following cases:
 Signature of applicant and father
 If you join late or after the date of refund is over. / guardian on every sheet of
 If you don’t join or attend even a single class at all after depositing the course fee. application form is must, otherwise
 Refund is only possible out of the First Installment before the dates mentioned above. form will be rejected.
 No Refund is allowed in Second Installment.  Mobiles are not allowed for
Boys. Girls can keep mobiles on
 No Fee will be refunded in case you leave after Last date of Refund mentioned above.
switched off mode in the campus.
 Our rules and regulations are applicable on you as mentioned here and in our latest brochure. Male students found with mobile
 Refund request through Email / Fax / Telephone / Mobile / SMS will not be entertained; it should be inside the campus will be fined as:
given in the prescribed format available with this brochure and the same must reach here on or before last First Time Rs.100/-, Second Time
date of refund in physical form. Rs.200/-, Third Time Rs.500 and
after that Mobile will be forfeited
 Refund rules are same whether you apply for refund without attending class.
forever.
 Late joining does not allow students to get benefit of 1 week time of refund.  Medium of instruction is English
 For any legal dispute jurisdiction will be Kota (Rajasthan) only. only and all literature provided by
us is solely in English.

Declaration: I have carefully read the Academic, Administrative & General Rules and Regulations of the Institute as given in the Instruction Manual and agree to abide by the
same. I hereby declare that if I clear the Selection Test and join the institute by paying necessary Fees, I will abide the refund rules of the institute if I withdraw from the course
after the expiry of refund date (as mentioned above). I hereby declare that the information provided by me in the Application Form are true and correct to the best of my
knowledge. My signature below certifies that i have read, understood and agree to the rules and regulation of the Institute including those mentioned in Instruction Manual.
All disputes are subject to Kota (Rajasthan) Jurisdiction.

Signature (Applicant) with date Signature (Father/Guardian) with date

You are advised to retain a photocopy of the completed Application Form for your records