NIIS INSTITUTE OF BUSINESS

ADMINISTRATION
Sarada Vihar, Madanpur, Bhubaneswar, Orissa, Pin 752054
Ph: -(0674)2113232, Fax: (0674)2113242, E-mail:niba_bbsr@yahoo.com, Webwww.niisinst.com

Application Form
1. APPLICATIION FOR ADMISSION INTO:
_____________________________________________________
2. RANK IN MAT/CAT/XAT/ATMA/JEE/CET (IF ANY):
___________________________________________
3. NAME OF THE CANDIDATE (IN BLOCK LETTER):
______________________________________________
4. (A) FATHERS NAME
:__________________________________________________________________
(B) MOTHERS
NAME:__________________________________________________________________
(C) GUARDIANS NAME (If father is not
alive):______________________________________________
(D) RELATIONSHIP OF GUARDIAN WITH
APPLICANT:_________________________________________
(E) OCCUPATION OF FATHER/GUARDIAN:
_________________________________________________
(STATE EXACT DESIGNATION OF SERVICE WITH DETAILS)
:____________________________________________
PH NO.
(RES):_____________________________(OFF)______________________________________
5. DATE OF BIRTH (DD/MM/YYYY):
________________________________________________________
6. NATIONALITY: ___________________________ (A) STATE TO WHICH STATE:
____________________
7. SEX :___________________________________ (A) BLOOD
GROUP:____________________________
8. IF SC/ST/OBC/GENERAL, SPECIFY:
_______________________________________________________
9. PRESENT ADDRESS:
___________________________________________________________________

_________________________________________________________
_________
PIN:____________________________PHONE (WITH STD
CODE):______________________________
10. PERMANENT ADDRESS:
______________________________________________________________
_________________________________________________________
_________
PIN:____________________________PHONE (WITH STD
CODE):______________________________
11. NAME & ADDRESS OF LOCAL GUARDIAN OF BHUBANESWAR WITH TEL
NO. IF ANY _____________
__________________________________________________________________________________
_
12. ACADEMIC QUALIFICATION:
EXAM
UNIVERSITY/BOARD/C
PASSED
OUNCIL

YEAR OF
PASSING

DIVISIO
N

%OF
MARKS

DECLARATION

I _________________________________________________________ hereby solemnly declare

that all the particulars furnished of the Institute, now in force and as
amended from time to time. The authority of the Institute can take any action
against me if I break the rules and regulations of the Institute. I also affirm
hat I will not discontinue before the completion of the course.

Date:
Place:
Signature of the Candidate

DECLARATION BY PARENT/GUARDIAN

I have gone through the prospectus of the Institute and hereby declare that
the application is made with my consent. I take the entire responsibility for
the good conduct of my ward, payment of full fees in time without default
and will not allow my ward to discontinue while in middle of the course.

Date:
Place:
Signature of the Parent/Guardian

FOR OFFICE USE ONLY

Year of Admission: _________________ MAT/CAT/XAT/ATMA/JEE/CET Rank No.:
__________________
Branch: __________________________ Roll No. :
_____________________________________________
Day Scholar/Hostelite:_____________ _ University Regd. No.
:___________________________________