1. Name of the Candidate:

Surname:

First name:

Father's name:

2. Residential Address: ________________________________________________________

_________________________________________________________________________

_______________________________________________Pin Code:

E-mail:___________________________________________________________________

Telephone No.

Mobile No.

3. Date of Birth: In figures:

(Date) (Month) (Year)

4. Sex: Male: Female: 5. I.P.M’s P.R.No

6. School's Name and Address:__________________________________________________

_______________________________________________Pin Code:

School Telephone No.

School E-mail:_____________________________________________________________

7. Medium of Examination: English Marathi

8. Details of Payment: Cheque Draft: Amount: 200/- (Rs.Two Hundred Only)

Cheque/Draft no. ___________________ Name of the Bank: ________________________

( Payments only by Cheque/ D.D.for Pune & Mumbai.out station students pay by D.D.only,

Drawn on Institute for Promotion of Mathematics. Last date of submission of application form 30 Nov.)

(Write the students name,schools name, standard and Phone No behind the Cheque/ D.D.)

9. I have read all the rules and regulations in the brochure and will abide by them.

10. Please keep a xerox copy of the Application form and the Brochure for your record.

Signature of the Candidate: ___________________________________________________

Date:_________________Signature of the Parent/Guardian: ________________________

Seal /Stamp of the School Signature of the Principal

APPLICATION FORMALL INDIA OPEN

MATHEMATICS SCHOLARSHIP EXAMINATION

Notes: 1. Fill all the information in English Capital Letters using Blue Ink only. 2. Write only one letter in one box wherever provided. 3. Use a tick mark ( ) wherever necessary.

SINCE-1996

STD. III: IV: V: VI: VII: VIII: IX:

STD:

Institute for Promotion of Mathematics 46/C,Aundh Road, 103-Prerna Building, Opp. HDFC Bank. Khadki, Pune - 411020.Phone No: (020) 2581 8606, 2581 0540 Visit vs at www.ipmindia.in

Medium:

(See mark sheet)

If appeared in 2008-09.