Application for Admission for Academic Year 2009

Plot No. 5, Knowledge Park-II, Institutional Area, Greater Noida (NCR), U.P. - 201306, INDIA Tel.: +91-120-2323001-10 Fax: +91-120-2323022/25 Website: www.bimtech.ac.in

Form Number: ______________________ (for office use)

Please paste your stamp size photograph here within the frame (Do not staple)

PLEASE FILL THE INFORMATION IN CAPITAL LETTERS.

Write strictly within the boxes without touching the boundary to avoid the rejection of form. 1. Candidate Name (in CAPITAL LETTERS):

2.

Date of Birth

3. Nationality: Indian

Foreign

4. Gender: M

(Tick '' Mark in relevant Box) 5. Mailing Address: House No. Street No. City Pin Code Mob. No. 6. 7. 8. E-mail-ID: Father's Name/Husband's Name: Academic Record: (Please attach self attested marks sheets of 10th, 10+2 & Graduation exam) Academic Details High School 10th Sr. Secondary 10+2 Graduation Any Other Degree* * For Appearing Mention Aggregate %age of Last Exam Year of Passing Board/University Name Degree Name Percentage% Tel No. State

9.

Work Experience in MNC/ listed Co./Pvt. Co/ Family run Company/Business/Educational Institution Name of the Company/organization/Institution Designation/Position From To Total Experience in months Achievements/ Awards

10. Details of the Bank Draft attached: Draft/Banker's cheque for Rs.600/- drawn in favour of BIRLA INSTITUTE OF MANAGEMENT TECHNOLOGY, payable at Greater Noida/Noida/New Delhi DD DD. No. Bank Branch Drawn Bank Name Date MM YY

11.

Candidate Category: S. No. 1. 2 3 4

Pls. refer Category Code Given Below Category Merit Corp. Sponsored NRI NRI Sponsored Code Number 01 02 03 04

12.

The social category of the candidate (please tick/ mark) General OBC ST SC

Declaration: This is to certify that the information provided by me in this form is true and correct. In case of any discrepancy BIMTECH has full right to cancel my candidature. DD Date: Place: MM YY

Signature of the Applicant (within the box) .