IES, 2012
For Office Use only
12, Masilamani Street, T. Nagar, Chennai 600 017.
Student No:
2
Affix Passport Size
Photo here
ENROLMENT FORM
POSTAL SUPPORT PROGRAMME FOR
ENGINEERING SERVICES EXAM, 2012
The Principal,
BRILLIANT TUTORIALS PVT. LTD.
4.5 4.5 cms
Enclose two additional
signed photographs
with this Form
PLEASE ENSURE THAT THIS IS THE COURSE YOU
WISH TO APPLY AND ENROL FOR.
COMPLETE AND SIGN BOTH SIDES OF THIS FORM
WHERE NECESSARY
Sir,
(Enrolment forms
will not be accepted
without three photographs)
Have you previously enrolled in any of our courses
Yes
No
If Yes, Course
Enrolment No.
B
REFERENCE NUMBER:
......
I have passed the Engineering Degree Examination or equivalent
in from
(Month year)
(Name of Institution/University)
I have appeared/intend to appear in the Engineering Degree Examination or equivalent
in from
Month/Year
Name of Institution/University
I am aware that my admission to the ESE will be provisional and subject to cancellation, if I do not produce proof of having passed the
qualifying examination when required to do so on the result of the written part of the examination.
Please enrol me as a student of your Postal Course for Engineering Services Exam, 2012, for
Mechanical Engineering
Electronics & Telecommunication Engineering
Electrical Engineering
I herewith remit the full course fee of Rs. 13,225/- (Fee: Rs. 11,990/- + Service Tax Rs. 1235/-) 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)
Date
Transaction Confirmation No.
Cash/ Credit Card at your Centre in
Date
Visa
Master Card
Credit Card Authorization Code
(See overleaf for list of Centres)
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 above
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.
BANK ROUTING DETAILS
All matters are subject to the exclusive jurisdiction of courts in Chennai only.
Pay to: BRILLIANT TUTORIALS PVT LTD.
Account No. 014010200034654
Bank, Branch: AXIS BANK LTD, T.NAGAR BRANCH,
CHENNAI 600 017.
IFSC Code For NEFT: UTIB0000014
Note: Payment by NEFT only. Bank charges to be paid by student.
Yours faithfully,
Signature of Applicant
Date:
(PLEASE PRINT IN BLOCK LETTERS)
Applicants Name (as in school records) ....................:
Date of Birth : Date Month Year
Category (General/SC/ST/Ex.S.)
Sex:
Male
Female
Whether departmental candidate
eligible for age relaxation
Yes
No
Permanent Home Address:
Telephone:
Own
Fax:
STD Code:
PP
Number:
E-Mail: *
Cell Phone: *
PIN CODE:
Name and Full Postal Address to which
all Correspondence and study material
should be despatched:
Telephone:
Own
Fax:
STD Code:
PP
Number:
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.
REMEMBER TO SEND TWO ADDITIONAL SIGNED PHOTOGRAPHS (PREFERABLY COLOUR) WITH THIS FORM.
Please keep a copy of this application for your records
CENTRES (for Cash or Credit Card Payment)
SOUTH INDIA OFFICES:
NORTH INDIA OFFICES:
CHENNAI - (Registered Office)
SOUTH DELHI
No.12, Masilamani Street, T.Nagar, Chennai 600 017.
50-C, Kalu Sarai (Behind Azad Apartments), New Delhi 110 016.
Tel: +91-44-2434 2099; Fax: +91-44-2434 3829
Tel: +91-11-2653 7392, 93, 94, 95. Fax: +91-11-2653 7396
BANGALORE
EAST DELHI
No.5, II Floor, Kasthuri Apartments, Near Double Road Junction,
13, Pratap Nagar, Mayur Vihar Phase-I,
Behind MRF Showroom, 35/22, Langford Road,
New Delhi 110 091. Tel: +91-11-2279 2226, 27, 28, 29.
Bangalore 560 027. Tel: +91-80-4144 2127, 2128
NOIDA
COIMBATORE
H-150, Sector-63, Noida. Tel: +91-120- 425 3316/17
No.41, Balasundaram Road, (RTO Office Road),
NORTH DELHI
Coimbatore 641 018. Tel: +91-422-4377 457, 458
19-20, Central Market, Punjabi Bagh (West),
KOCHI
New Delhi 110 026. Tel: +91-11-2522 1424, 25.
39/4210, Ground Floor, M.G.Road, Near Sarada Math, Ravipuram,
PITAMPURA
Kochi 682 018. Tel: +91-484-4028 770, 771
1, Kohat Enclave, Pitampura,
KOTTAYAM
New Delhi-110 034, Ph.: +91-11-2735 1180, 2735 1181
II Floor, Kalarickal Building, South Manorama,
WEST DELHI
Kottayam 686 001. Tel: +91-481-2585 152
A-1/295, Janakpuri (Pankha Road),
MADURAI
New Delhi 110 058. Tel: +91-11-2552 7515, 16, 17, 18
72/193, Meenas Building, Bye-Pass Road,
DWARKA
Madurai 625 016. Tel: +91-452-4351 075
Raj Laxmi Plaza, Plot No. 15, Sector 5, Dwarka,
MYSORE
New Delhi 110 075. Tel: +91-11-2508 6117, 18
MIG-7, 1st Floor, 1st Stage, Udaya Ravi Road,
GURGAON
Mysore 570 023. Tel: +91-821-4262 128/4264 127
M-1, Old DLF Colony, Sector 14,
SALEM
Gurgaon 122 001. Tel: +91-124-426 8015, 426 8016
454/4, Ram Complex, II Floor, Near Bus Stand, ARRS Multiplex Road,
MEERUT
Salem 636 009. Tel: +91-427-4265 779
2nd Floor, Kumar Plaza, Begum Bridge, Meerut. . Tel: +91-121-402 9280, 81
TRIVANDRUM
PATNA
C-1, Future Plaza, Dhanya Remya Theatre Road, Kunnumpuram,
Plot No. 4, Jugeshwar Bhawan, First Floor, S.K. Puri, Boring Road,
Trivandrum- 695 001. Tel: (0471) 4010 999
Patna . Tel: +91-612-2540951, 52
TRICHY
RANCHI
D-110, 9th Cross, East Thillai Nagar,
8, U.G.F., Near Gesonar College City Centre, Club Road
Trichy 620 018. Tel: (0431) 4023 353, 363
Ranchi. . Tel: +91-651-246 1307, 1308
HYDERABAD
BOKARO
Sri Kamakshi Bhavan, 1-8-702/B/1, Ground Floor, Shankar Mutt, V.S.T. Road,
Plot No. A-16, Second Floor, City Centre, Sector-4
Hyderabad. Tel: 040-27665570, 99126 78880 / 81
Bokaro Steel City. Tel:+91-6542-233 018, 019
