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Gate Form 12

The document is an enrollment form for a support program to prepare for the GATE exam in 2012 offered by Brilliant Tutorials Pvt. Ltd. It contains information about the courses offered such as engineering subjects, life sciences subjects, fees for study material only or study material with optional test series. The applicant is asked to select the relevant subjects, payment options and provide contact details for registration.

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shafignits_123
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© Attribution Non-Commercial (BY-NC)
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Download as PDF, TXT or read online on Scribd
50 views

Gate Form 12

The document is an enrollment form for a support program to prepare for the GATE exam in 2012 offered by Brilliant Tutorials Pvt. Ltd. It contains information about the courses offered such as engineering subjects, life sciences subjects, fees for study material only or study material with optional test series. The applicant is asked to select the relevant subjects, payment options and provide contact details for registration.

Uploaded by

shafignits_123
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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For Office Use only

12, Masilamani Street, T. Nagar, Chennai – 600 017. Student No:E G 1 2

Affix Passport Size


Photo here

4.5 × 4.5 cms


Enclose two signed
ENROLMENT FORM photographs with this
SUPPORT PROGRAMME FOR Form
GATE, 2012
(Enrolment Forms
The Principal, PLEASE ENSURE THAT THIS IS THE COURSE will not be accepted
YOU WISH TO APPLY AND ENROL FOR.
BRILLIANT TUTORIALS PVT. LTD. without three
COMPLETE AND SIGN BOTH SIDES OF THIS photographs)
Sir, FORM.

I have passed/will pass …………………………………… in …………………………


(Name of Course) (Month/year)
from …………………………………………………………… DO NOT REMOVE THIS LABEL OR WRITE IN THIS SPACE
(Name of Institution and Place)
Discipline (Major Subject) ………………
Have you previously enrolled in any BT Course?
Yes No
If Yes, Course …………………….,,………………...……
Enrolment No.
FOR OFFICE USE ONLY

Please enrol me as a student of your Support


Programme for GATE 2012:
Postal Course with Online Test Series
Postal Course only
Online Test Series only
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 Date


Net Banking/Credit Card/Online Bank Transfer Visa Master Card
(Bank routing instructions given below) Transaction Confirmation No. Date
Cash/ Credit Card at your Centre in Credit Card Authorization Code
Last 4 Digits of Card No.
I would like to receive all updates as text messages on my cell phone number given below* Yes No
(Please 3 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.
All matters are subject to the exclusive jurisdiction of courts in Chennai only. BANK ROUTING DETAILS
Pay to: BRILLIANT TUTORIALS PVT LTD.
Yours faithfully,
Account No. 014010200034654
Bank, Branch: AXIS BANK LTD, T.NAGAR BRANCH,
CHENNAI – 600 017.
Signature of Applicant IFSC Code For NEFT: UTIB0000248
Note: Payment by NEFT only. Bank charges to be paid by student.
Date:
(PLEASE PRINT IN BLOCK LETTERS)
Applicant’s Name (as in school records)..…...........……………………….:
Date of Birth : Date …………… Month ……………… Year …………… Sex: Male Female

Permanent Home Address:

Telephone: STD Code: Number: Cell Phone: *


Own PP

Fax: E-Mail: * PIN CODE:

Name and Address to which all Correspondence


and study material should be despatched:

Telephone: STD Code: Number: Cell Phone: *


Own PP
Fax: E-Mail: * PIN CODE:
Our course material is in the English Medium only • Fee 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. *E-mail address and Cell Phone Number mandatory
REMEMBER TO SEND TWO ADDITIONAL SIGNED COLOR PHOTOGRAPHS WITH THIS FORM.
Please keep a copy of this enrolment form for your records
GATE 2012
I. ENGINEERING SUBJECTS:
STUDY MATERIAL ONLY

INSTRUMENTATION ENGINEERING (IN) Rs. 15,828/- (Fee: Rs.14,350/- + Service Tax Rs. 1478/-)

PHYSICS (PH) Rs. 10,854/- each (Fee: Rs. 9840/- + Service Tax Rs. 1014/-)

STUDY MATERIAL WITH (OPTIONAL) TEST SERIES

Engineering Subjects (Choose one)


Mechanical Engineering (ME) Computer Science & Info. Technology (CS)
Electrical Engineering (EE) Production and Industrial Engineering (PI)
Electronics and Communication Engineering (EC) Biotechnology (BT)
Fees:
Study Material only : Rs. 15,828/- (Fee: Rs. 14,350/- + Service Tax Rs. 1478/-)
Study Material + TS9 : Rs. 18,608/- (Fee: Rs. 16,870/- + Service Tax Rs. 1738/-)
Study Material + TS5 : Rs. 17,769/- (Fee: Rs. 16,110/- + Service Tax Rs. 1659/-)
TS9 Test Series only : Rs. 2780/- (Fee: Rs. 2520/- + Service Tax Rs. 260/-)
TS5 Test Series only : Rs. 1941/- (Fee: Rs. 1760/- + Service Tax Rs. 181/-)

II. LIFE SCIENCES (XL)


Please 3 all the options you would like to take.
Chemistry CHOOSE ONE OR BOTH SUBJECTS
LIFE SCIENCES (XL) (Compulsory)
(H) Biochemistry (I) Microbiology (K)

Study Material only

Study Material + TS9 Test Series

Study Material + TS5 Test Series

TS9 Test Series only

TS5 Test Series only

Fees: Study Material Only:

a. Compulsory Subject with two Optionals : Rs. 14,835/- (Fee: Rs. 13,450/- + Service tax Rs. 1385/-)
b. Compulsory Subject with one Optional : Rs. 10368/- (Fee: Rs. 9400/- + Service tax Rs. 968/-)
c. Two Optionals without Compulsory : Rs. 8934/- (Fee: Rs. 8100/- + Service tax Rs. 834/-)
d. One Optional without Compulsory : Rs. 4467/- (Fee: Rs. 4050/- + Service tax Rs. 417/-)
e. Compulsory Subject only : Rs. 5901/- (Fee: Rs. 5350/- + Service tax Rs. 551/-)

Fees: Study Material with (Optional) Test Series:

Chemistry (Compulsory) + TS9 : Rs. 8681/- (Fee: Rs. 7870/- + Service tax Rs. 811/-)
Chemistry (Compulsory) + TS5 : Rs. 7842/- (Fee: Rs. 7110/- + Service tax Rs. 732/-)
Study material + TS9 : Rs. 7247/- (Fee: Rs. 6570/- + Service tax Rs. 677/-) each
Biochemistry / Microbiology
Study material + TS5 : Rs. 6497/- (Fee: Rs. 5890/- + Service tax Rs. 607/-) each
Biochemistry / Microbiology

Add: Additional Test Series Chosen: For EACH Optional TS9: Rs. 2780/- TS5: Rs. 1941/-

TOTAL FEES (for XL option): Rs. /-


Student’s Signature: Date :

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