For M. Tech.

Students

Visvesvaraya National Institute of Technology, Nagpur 440010

(Forwarded Through Training and Placement Department )
I D No. ______________________

Merit No. _____________________

Roll No. : ____________________

Name of the Industry/Organisation:____________________________________________________________________
1.
1.1

GENERAL
Name: __________________________
Surname

1.2

Date of Birth :

___________________________
First Name
1.3

Day

Month

Whether SC

ST

____________________________
Fathers Name
OBC

PWD

(Pl. tick )

Year

1.4

Height : ___________ cms.

Weight : ____________ kg.

1.5

Present Address : ____________________________________________________________________________

_____________________________________ PIN

1.6

Address for contacting: ________________________________________________________________________

(after annual examination) ______________________________ PIN
Phone (R) ______________________________

1.7

E-Mail Address : ________________________________ Mobile No._____________________ ___________

2.

EDUCATIONAL QUALIFICATIONS

2.1

Secondary and / or Higher Secondary

Examination
Passed

Board / Institution

Year of
Passing

Obtained

Marks
Out of (Total)

No. of Attempt
(s)

S.S.C. or
Equivalent
H.S.S.C. or
Equivalent
2.2

Graduation

Examination Passed

Institution / University

Year of

CPI / Grade /
Division

P
a
s
s
i
n
g

2.3

Post Graduation

Examination
Credits earned
Passed
1st Sem M.Tech.
2nd Sem M.Tech.
3rd Sem M.Tech.
4th Sem M.Tech.
Total
Present CPI : __________

Year of Passing

__

Grade
SPI
CPI

__

Page 1 of 2

__

No. of Attempt
(s)

2.4

Title of Project in Final Year : ________________________________________________________

Name of Guide :

2.5

____________________________________________________________

Additional Qualifications, if any

____________________________________________________________________________________

3.

FAMILY BACKGROUND : Please provide full details since the employer usually needs this information for record.

Relations

Name

Age

Education

Occupation if employed
(Specify Designation &
Office Address)

Annual
Income
(Approx)

Father
Mother
Brothers
Sisters
4.

PRACTICAL TRAINING
Have you undergone practical training ?

Yes

No.

If yes, provide details below

Sr. No.

5.

From

To

EXTRA CURRICULAR ACTIVITIES

Sr. No.

6.

Period

Name of Organisation

Name of Activity

Level of Participation :
College/University/District / State/
National

Year of Participation

ADDITIONAL INFORMATION, IF ANY

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Date : ------------------------

Signature ------------------------

Page 2 of 2