Application form for VITEEE - 2015

Full Name

: KUKADIYA KAUSHIKBHAI VINESHBHAI Application. No. : 2015118002

Date of Birth

: 01/11/1997

Gender

: MALE

Religion

: Hinduism

Nationality

: Indian

Community

: General/OC

Mother Tongue

: Gujarati

Native State

: Gujarat

Mode of Study

: Regular

Landline No.

: -

Mobile No.

: 8690737086

Parent name

: KUKADIYA VINESHBHAI MULJIBHAI

Hostel

: Yes

Choice of Campus

: Chennai

Email ID.

: jalteshghevariya@gmail.com

Qualifying Exam

: 12th Class

Month & Year Passing

: Mar - 2015

Exam Roll.No./Reg.No.

Testcity

: SURAT

Permanent Address

: 111, SHIV SHANKAR PARVATI SOC.,SURAT,SURAT,GUJARAT,395006.

Name of the School

: RAMKRUSHNA VIDHYABHAVAN

Address of the School

: L.H. ROAD, SURAT, SURAT,GUJARAT, 395006.

DECLARATION
I solemnly and sincerely affirm that I am an Indian National and that all particulars
furnished by me in this application form are true and correct . I have not concealed any
information. However, in the event of any information being found to be incorrect,
fraudulent or untrue, either before or after the examination or after my admission to the
programme, I understand that I am liable to face criminal prosecution and the
management can claim all authority to cancel my candidature / selection or admission
as the case may be and I would have to forego my seat and the fees.
I agree to abide by the rules and regulations governing the examination as well as the
rules pertaining to the refund of tuition and hostel fees contained in the brochure.
I further undertake to submit all the required certificates as per the rule, either at the
time of counselling or during the admission process, failing which I understand that I
would have to forego my seat and the fees.
I have read the brochure and understood the contents in general and the method of
Equipercentile Equating in particular.
I accept this method to be adopted for Merit List preparation by VIT.

Signature of the Applicant

Payment Acknowledgement Copy

VIT ONLINE APPLICATION SALE
Payment Option Made:-NetBanking / Credit Card / Debit Card.
Bank Reference No.:201501319102286

Transaction No.:139755357

Applicant Name:KUKADIYA KAUSHIKBHAI VINESHBHAI

Application No.:2015118002

Contact No.:8690737086

Transaction Date:31-01-2015 10:02:54

Application Fee :

940.00 (excluding bank charges.)

Amount in words: Rupees Nine Hundred And Forty Only.

Note :
1. Do not send the hardcopy of the application form.
2. Retain a photocopy of the completed application form with you.