Are you already Enrolled / Registered in FIITJEE / USA UnivQuest ? If yes, please provide the following info below:

1. Details about the Student:

Application Form No.

a) Enrollment Number Registration Number

b) Students ID Mobile Number

a)

b)

c)

d)

(g) How do you want to receive the Hall Ticket E-Mail Printed

(Printed Hall Tickets will be issued only if this Application Form is submitted to a FIITJEE / USA UnivQuest office in person.)

First Name Middle Name/Initials Surname

e

f

(a) E-Mail IDs and Mobile Nos.

E-Mail ID (Please Fill in BLOCK Letters Only) Mobile Number

Student

Father

Mother

What is your preferred e-mail ID Student Father Mother What is your preferred Mobile No. Student Father Mother

Non-Engineering: Pure Science Business & Commerce Humanities Medical Others, please specify

(b) Correspondence Address: (c) Permanent Address: (Please mention only if different from Correspondence Address)

(Please do not write your / your Father’s name in these address boxes. Fill the address only within the space provided in boxes.)

Pin Pin

* (for Class 8th fill 08, Class 9th fill 09, Class 10th fill 10, Class 11th fill 11, Class 12th fill 12 & Class 12th Pass fill 13).

APPLICATION FORM

Details to be filled in (for Registration Centre, Study Centre, Test Centre & Segment Codes, please refer to point no. 1, 2 & 3 of relevantInformation Booklet):

Your Brahmastra

for Best Education in the World

5. Details about Parents (in BLOCK Letters only)

Mother's Name …………………………………………………………..………..

Qualification Occupation . Designation Office Name / Address Contact Nos

Father's / Legal Guardian Name …………………………………………………………..………..

Qualification Occupation . Designation Office Name / Address Contact Nos

8.

USA UnivQuest National Admissions Office:

32 & 32/1, Chaudhary House, Kalu Sarai, Sarvapriya Vihar,

New Delhi - 110016, Ph.: 011 - 46024602

Web: www.usaunivquest.com

I / we have received & read the Terms & Conditions printed in the information booklet of the Test Date mentioned against Point No. 2 (a) of this Application Form and promise to abide by the same.

I have also cross verified the Codes filled in above Point 2 and I understand if an error occurs in the registration due to wrong codes it will not be corrected by USA UnivQuest/FIITJEE.

Test Date, Test Centre Code, Program Code etc. cannot be changed once registered.

Registration Fee will not be refunded in any case.

I authorize USA UnivQuest/FIITJEE to contact and send communication / information by SMS, e-mail, post on the above mentioned communication details given by me.

USA UnivQuest/FIITJEE reserves the right to offer study centre other than the one opted by student, subject to availability / constraints of seats.

Once a student joins the study centre offered (irrespective of his / her choice of study centre opted before joining), no request for change of study centre will be entertained, nor the course fee paid will be refunded under any circumstances.

USA UnivQuest/FIITJEE reserves the right to change / cancel any Program, Test Date, Test Centre, Study Centre, eligibility criterion & Course Fee without prior notice.

The Registered Office of USA UnivQuest Pvt. Ltd. is at New Delhi. In case of dispute, students / parents are subject to the exclusive jurisdiction of appropriate courts in Delhi / New Delhi only. All disputed shall be referred to the Sole Arbitrator appointed by the Management of USA UnivQuest Pvt. Ltd. The decision of the arbitrator shall be final & binding. The arbitrator so appointed shall not be incapacitated for reasons of their being the employee of USA UnivQuest Pvt. Ltd. or its sister concerns and for reasons of having any prior linkage with the company.

NTSE JSTSE NSEJS KVPY Olympiads SAT SAT Subject Test TOEFL Others

Newspaper Advt. Social Media News Paper Insert Banner / Poster Website E- Mailer

Hoardings Radio Present / Ex-Student Friends / Relatives Through Faculty

if other source (please specify)

9. How did you come to know about USA UnivQuest Programs ?

6.