Sri Balaji

College of Engineering & Technology P.G. Mahavidalaya College of Pharmacy Teachers Training College Benad Road, Jaipur-302013 APPLICATION FORM FOR 20____- 20______ For Office Use Only Form No. Student ID

A. Name of the Program: M.Tech/B.Tech./MBA/MCA/BBA/BCA/B.Pharmacy/M.Ed/B.Ed/NTT (Branches/Specialisation______________________________________)

B. List B.Tech Courses in Order of References:

1. Full Name (IN CAPITAL): (As Per Secondary Certificate):

2. Fathers Name (IN CAPITAL):

3. Mothers Name (IN CAPITAL):

4. Date of Birth:

5. Birth State: ___________________ 6. Sex: Male/Female_________________ 7. Nationality: ____________________ 8. State of Domicile: ________________ 9. Marital Status: Married Unmarried

10. E-Mail: _________________________________________________________ 11. Category: GEN OBC SC/ST OTHERS

12. Name and Relationship with guardian_______________________________ 13. Address for Communication:

Country PIN Phone No: Mobile:

14. Permanent Home Address:

Country PIN Phone No: Mobile: 15. Details of Demand Draft:

Bank and Branch of Issue:

D.D. No
D D M M Y Y Y Y

Rs.

Dated:

Payable at__________________________________________________________ 16. Academic Record: RPET/RMAT/RMCAAT/RPPT/AIEEE/OTHERS (Mention) ______________ Roll No. _________________________ Rank_____________________________

Exam Passed Secondary

Subject

School/ College

Board/ University

Year Marks Division Of Passing

Senior Secondary Graduation (-------------) Post Graduation (-------------) Others (-------------)

17. Academic Record/Professional Experience (For M.Tech. Courses Only) (A) Relevant National Level Examination Qualified* GATE

Year Appeared________ Valid Up to_________ Percentile/Other Score______ Discipline Selected in Gate____________________________________________ (B) Name of Qualifying Degree Course with Specialization_________________ Duration of the Course______________Year of Graduation________________ Discipline/Subject___________________________________________________ Name of the Institute_________________________________________________ Name of the Affiliating University______________________________________ (C) Name Project in B.E./B.Tech_______________________________________
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(D) Research Experience______________________________________________ (E) No. of Papers Published (i) National_________ (ii) International_________ (F) Teaching Experience (Yrs) ______ (G) Professional Experience (Yrs) _____ 18. Declaration by the Candidate 1. I have read the rules and regulations in the information brochure regarding admission to the relevant course of study. I solemnly affirm that all information furnished by me in the application form, as also to the enclosures is true. I understand that, if any information furnished there is in found to be untrue in materials particulars. I shall be liable to criminal prosecution and would also be removed from the college, if already admitted. I also affirm that I abide by the decision of the admission committee. 2. I understand to pay the college, hostel and other dues regularly, if admitted. 3. I agree, to abide by the rules and regulations in force or those that may hereafter br, made by the administration of the college that will interface with its orderly working and discipline as long as I remain a student of the college. 4. I also declare that I have never been convicted of any criminal offence, nor have I ever released on bail in connection with any criminal case. No case of criminal offence or moral turpitude is pending against me in any court of law. No complaint of F.I.R. has ever been logged against me by the school/college/university. 5. I have not resorted to any acct if indiscipline/ malpractice in the previous years. I understand that the college reserves the right to cancel my admission at any time during my stay at the college, if the college is satisfied that it was in the interest of the college to do so. 6. The admission once given is for full duration of the respective courses of studies. Anybody, willing to leave prematurely, can do so only by paying fee for the entire duration of the course. 7. The documents deposited with the college will be released only in the final year/semester of the course after realizing the fee for the full course. 8. All disputes related to the admission and subsequent course of studies are to be legally resolved in the courts of jaipur, rajasthan only. Place: _____________ Date: ______________
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Signature of the Candidate

19. Undertaking for not indulging in any kind of raging and indent behaviour towards juniors as a senior student I_______________________________________________ son /daughter/ward of Mr./Mrs. _________________________________________ hereby declare given an undertaking that I will not indulge in any kind of ragging or indecent behavior towards my junior students during my entire stay at jaipur. Also, I am aware of the fact that at any stage if I am found to violate the above undertaking, the college authorities may take suitable action against me that includes even expelling me from the institute. I will not challenge action taken for such violation in any court of law.

Date: Counter Signature of the parent 20. Parent/Guardians Declaration:

Signature of Student

1. I undertake to pay all college fees and subsidiary dues in respect of my ward/son/daughter ________________________________ who is being admitted to your college. My profession is ___________________________ and my approx. annual income is Rs._________________ have sufficient means to defray the expenses to be incurred during his/her studies in the college. 2. I hereby assures that my ward/son/daughter will abide by all the ordinances and regulations of the college. 3. I hereby certify that the entries made by my ward in this form are correct to the best of my knowledge and belief.

Place: Date: Signature of Parent/Guardian Full Name____________________________

Enclose Photo Copies of the following (Please Tick): 1. 3 Passport Size Photographs 2. Mark Sheet(X & XII) original plus two attested photocopies 3. Mark Sheet of degree (B.E./B.Tech.) original plus two attested photocopies 4. Gate Score Card 5. Certificate of State of Domicile from competent authorities. 6. Cast/Category Certificate (In case of reserved category candidates) 7. Other Certification (Please Mention)