Application form for VITEEE- 2012

Full Name
Date of Birth Mode of Study Community Month & Year passing XII Board Permanent Address School Address

: PRABHAT KUMAR
: 15/10/1994 : REGULAR : OBC/BC : MAR - 2012

Application. No. : 2012383182

Gender Nationality Email ID Religion : MALE : INDIAN : prabhatkr24@gmail.com : HINDUISM Native Landline Mobile No. Qualifying Exam Test City : DELHI - 15 : : 9312251529 : 12th Class : DELHI - 124

Parent/Guardian Name : PRAMOD KUMAR VERMA

Reg.No. / Roll.No. :

: 04 - CENTRAL BOARD OF SECONDARY EDUCATION. : S/O PRAMOD KUMAR VERMA (P.A) ,SPEED POST BRANCH, G.P.O ,KASHMERE GATE, DELHI - 110006.

: KENDIYA VIDYALYA ,DELHI - 110088.

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 interview or during the admission process, failing which I understand that I would have to forego my seat and the fees.

Paste here firmly your recent color passport size photograph of good quality.

Date : Place : Signature of Parent / Guardian Signature of the Applicant

___________________________________________________________________________________________________________________________________________________________

INDIAN BANK ( TO BE FILLED IN BY BANK )

Candidate Name: PRABHAT KUMAR Address : S/O PRAMOD KUMAR VERMA (P.A), SPEED POST BRANCH, G.P.O ,KASHMERE GATE, DELHI - 110006. Mobile. No. :9312251529 Amount Payable in Figures(incl. bank charges)Rs.930 (Appli.cost Rs.900 + Bank Charges Rs.30) Amount Payable in words(incl. bank charges): Rupees Nine Hundred and Thirty Only. Application No. : 2012383182 Date of Birth : 15/10/1994 VIT Account No. : 990036970 MUP Ref.No. : MU001353056 Branch Code : Tran.No. / Journal No. : VIT COPY

Branch Seal(within box)

Date of Deposit : ___ / ___ / ______

( Authorised Signatory )
(Signature of the Candidate) Kindly take the photocopy of this application form and the original should be sent to Admissions officer,VIT University,Vellore-632014.

--------------------------------------------------------------------------Cut here ---------------------------------------------------------------------------INDIAN BANK ( TO BE FILLED IN BY BANK )

Candidate Name: PRABHAT KUMAR Address : S/O PRAMOD KUMAR VERMA (P.A), SPEED POST BRANCH, G.P.O ,KASHMERE GATE, DELHI - 110006. Mobile. No. :9312251529 Amount Payable in Figures(incl. bank charges)Rs.930 (Appli.cost Rs.900 + Bank Charges Rs.30) Amount Payable in words(incl. bank charges): Rupees Nine Hundred and Thirty Only. (Signature of the Candidate) Application No. : 2012383182 Date of Birth : 15/10/1994 VIT Account No. : 990036970 MUP Ref.No. : MU001353056 Branch Code : Tran.No. / Journal No. : BANK'S COPY

Branch Seal(within box)

Date of Deposit : ___ / ___ / ______

( Authorised Signatory )

VITEEE - 2012 Application. No. : 2012383182 Applicant Name : PRABHAT KUMAR

BY REGISTERED POST / SPEED POST ONLY

To
Mode of Payment
Demand Draft ( DD ) Challan Net Banking (Indianbank only) Other Banks

: : : :

THE ADMISSIONS OFFICER, VIT University, Vellore - 632014, Tamil Nadu, INDIA.

-------------------------------------------------------------------------------------------------------------------------------------------------------- The Above address may be pasted on the envelope

Student Copy

PLEASE INSERT THE APPLICATION FORM IN THE ENVELOPE IN SUCH A MANNER THAT THE BARCODE ON THE APPLICATION FORM IS NOT FOLDED.

CHECKLIST FOR THE CANDIDATE

1.Tick the box if you have enclosed the following documents: a. Completed Application Form with your signature. b. Completed Application Form with your parent's / Guardian's signature. c. Your color photograph (of size 3.5 cm x 4.5 cm) affixed on application appropriately. d. Have you entered your correct Date of Birth. 2.Retain a photocopy of the completed application form with you. 3.Send your application form to the VIT as mentioned on the address slip