Kshitij Education India provides coaching for IITJEE, AIEEE, and medical entrance exams. The document contains an application form for their courses, requesting information such as the applicant's name, photo, family details, academic history, and contact information. It also contains the applicant's declaration agreeing to abide by Kshitij's rules and allow the use of their results and information for promotional purposes if accepted.

1. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
Application Form
(Target Exam – IITJEE/AIEEE/AIPMT)
Latest
Photograph
Course Applying For
Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij Kshitij
E - 13 E-12 E-11 M-13 M-12 M-11 B-12 B-12 F-10 F-9
PCM PCB
1.Name of the Applicant
2.Father’s Name
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

2. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
3.Mother’s Name
4. State of Domicile
5.Date of Birth
Date Month Year
6.Gender
Male Female
7.Category
General OBC SC ST DS PD
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

3. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
8.Religion
9.Permanent Address
10.Address of Correspondence (All study
materials and test papers will be sent at this
address) with phone/mobile number
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

4. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
11.Medium of Studies to be opted in Kshitij
Education India
Hindi English
12.Past Performance in Competitive/Talent
Examinations, fill if relevalent
S. Competitive Year Level Max Marks % Remarks,
No Or Talent (Qualified) Qualified Marks Obtained Marks (AIR) (ASR) if any
Examination (1/2/Final)
1. NTSE
2. Olympiads
3. KVPY
4. IITJEE
5. AIPMT
6. AIEEE
7. Other
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

5. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
13.Parent’s/Guardian’s Occupation
14.Past four year’s Acadmic Performance
Class Year of Name City/Town/Village District State Board % %
Passing of the Marks/Grade Marks/Grade
Out School Aggregate in PCM/B
12
11
10
9
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

6. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
15. Address and Phone No. of Class 10
School
16.Address and Phone No. of Class 12
School
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

7. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
17.Emergency Mobile No./Email (other
than Parents)
Name Mobile No. Email
18.How did you come to know about Kshitij
Education India? (Write in 30 words)
19.Parents/Guardian’s Bank Account
Detail
Account Relationship Account Bank City Branch
Holder’s with Number
name Student
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com

8. KSHITIJ EDUCATION INDIA
FOR IITJEE/AIEEE/Medical Entrance Exams
Delhi | WB | Bihar | Noida | Gurgaon | MP | CG | AP | UP
Declaration
I/We undersigned, hereby assure that the information given in the application form (as well as in all
relevant documents i.e. Cheques, Demand Drafts etc.) is true and correct. I/We have understood and
agreed that my misrepresentation or concealment of facts will justify the denial/cancellation of
undesired student’s admission, or expulsion from the institute at any stage of the academic session.I
have read and hereby provide my/our free consent to the terms and conditions of application form and
mentioned on the website for admission is the institute for the academic session 2012-2013 further, if
undersigned is admitted I/We promise to abide by all the rules and regulations and norms of discipline
of the institute as long as undersigned student remains a registered student of Kshitij Education India.
I/We hereby also declare that while being an enrolled student of Kshitij Education India, undersigned
student will be responsible in terms of providing relevant details of all the competitive examination
(in form of true photocopies of the application form of the relevant examination) while he/she will be
appearing in the future by virtue of coaching and academic support from the institute. If the
undersigned student, as registered student succeeds in any of these competitive examination, Kshitij
Education India will have all the rights of using his/her result, photo graph and testimonials in any
form for its growth strategies and development plans. In such cases I/We never have any objection or
protest for this.
Signature of Student Signature of Parent
Date:- Date:-
Place:- Place:-
Note:- In case of any dispute, the Jurisdiction of the Court of Delhi will be applicable
Corporate Office- B-206, Sec. 7, Dwarka, Palam Extension, New Delhi-110045
Contact No. – 011 64599348, 011 64739348, 011 64599348, 011 65659348
Email Id- info@kshitij-iitjee.com, info@kshitij-pmt.com, info@kshitij-school.com
Website- www.kshitij-iitjee.com, www.kshitij-pmt.com, www.kshitij-school.com