ENGINEERING & TECHNOLOGY MANAGEMENT MEDICINE & HEALTH SCIENCES SCIENCE & HUMANITIES

Application Number
"To be alloted by the University upon receipt of filled application and the same will be intimated to the applicant."

1. PHOTOGRAPH

Fill details in English using CAPITAL letters Read carefully the instructions to fill details Use black or blue Hi-Tech point for filling details Mail the filled application to : Director (Admissions), SRM University, SRM Nagar, Kattankulathur 603 203, Kancheepuram Dt., Chennai Area, Tamilnadu, India.

Paste your passport size color photograph Do not pin or staple

ADMISSION 2013

2. NAME OF THE APPLICANT

Signature of Applicant

3. GENDER

4. RELIGION

5. NATIONALITY

MALE FEMALE

6. COMMUNITY General / OC 7. DATE OF BIRTH OBC BC MBC 8. MOTHER TONGUE SC ST 9. NATIVE STATE

SRM UNIVERSITY

DATE

MONTH

YEAR

10. NAME OF THE PARENT / GUARDIAN

11. ADDRESS FOR CORRESPONDENCE (DO NOT REPEAT NAME)

12. CITY

13. DISTRICT

14. STATE

15. PIN CODE

16. STD CODE

17. TELEPHONE NUMBER

18. MOBILE NUMBER

19. E-MAIL ADDRESS

20. DETAILS - XIIth AND Xth STANDARDS

SCHOOL EXAM SCHOOL BOARD (CODE) REGISTRATION NUMBER MONTH / YEAR OF PASSING % OF MARKS

XII X 21. DETAILS OF QUALIFYING EXAMINATION FOR UG / PG / PG DIPLOMA PROGRAMS

EXAMINATION COLLEGE UNIVERSITY REGISTRATION NUMBER MONTH / YEAR OF PASSING AGGREGATE % MARKS

22. PARENTS OCCUPATION

ADMISSION 2013

23. PARENTS INCOME (`)

Below 50,000 50,001 to 1,00,000 1,00,001 to 2,00,000 2,00,001 to 4,00,000 Above 4,00,000

24. PROGRAM APPLIED GROUP - I B. TECH M. TECH M.B.A. M.C.A.

HEALTH SCIENCES UG

GROUP - II B. ARCH B. DES PGPM

GROUP - III PGPRM M. ARCH HUMANITIES

SCIENCE &

24(a): OPTION FOR ONLINE EXAM (ONLY FOR GROUP 1) YES NO

24(b): TEST CITY CENTRE FOR ONLINE EXAM (ONLY FOR GROUP 1)

SRM UNIVERSITY

1 24: CHOICE OF ONLINE EXAM SLOT (ONLY FOR GROUP 1) 25. TEST CITY (PAPER-PENCIL EXAM) [ONLY FOR GROUP 1]

26. BRANCH / SPECIALIZATION

CHOICE 1

CHOICE 2

CHOICE 3

27. PAYMENT OF APPLICATION FEE OF ` 900/- TO BE DRAWN IN FAVOUR OF SRMIST, PAYABLE AT CHENNAI PAYMENT MODE DEMAND DRAFT 28. DECLARATION I hereby declare that I have carefully read the instructions and particulars supplied to me and that the entries made in this application form are correct to the best of my knowledge and belief. I note that the decision of the University is final in regard to selection for admission. If selected for admission, I promise to abide by the rules and regulations of the University and the guidelines in the prospectus. The University shall have the right to expel me from the University at any time after admission, provided it is satisfied that I was admitted on false particulars furnished by me or my antecedents prove that my continuance in the University is not desirable. I agree that all disputes are subject to the jurisdiction of the courts at Chennai only. Fees paid on counseling and admission will not be claimed back under any circumstances. NUMBER AMOUNT (`) DATE ISSUING BANK NAME BRANCH

SIGNATURE OF PARENT / GUARDIAN

SIGNATURE OF APPLICANT

DATE

INSTRUCTIONS FOR FILLING APPLICATION

ENGINEERING AND TECHNOLOGY, MANAGEMENT, MEDICINE & HEALTH SCIENCES, AND SCIENCE & HUMANITIES
1. PHOTOGRAPH: Paste your most recent colour photograph in the given space. Do not staple or pin the photograph. The Applicant to sign within the box below the photograph. 2. NAME OF THE APPLICANT: Write your name in CAPITAL LETTERS as it appears in your xth standard mark sheet. Leave one blank box between adjacent words. Do not add any prefixes like Dr., Mr., Mrs., Miss. Ms. etc. For example, MR. RAVI SUNDAR SINGH should be written as:
R A V I S U N D A R S I N G H

3. GENDER: Tick the appropriate box.

MALE

FEMALE

4. RELIGION: Fill up your religion. For example, if your religion is Hindu, it should be written as:

5. NATIONALITY: Write your nationality. For example, if you are an Indian, it should be written as:

6. SOCIAL STATUS / COMMUNITY: Fill your Social Status / Community. For example, if you belong to OTHER CASTE, tick as below: GENERAL / OC OBC BC MBC SC ST

7. DATE OF BIRTH: Enter the date, month and year of your birth as recorded in 10th standard mark sheet in DD/MM/YY format only. For single digit numbers, zero should be prefixed. For example, 27th January, 1993 should be written as:

8. MOTHER TONGUE: Refer to the table below for codes. For example, if your mother tongue is Hindi, write as below:

LANGUAGE Assamese Bengali Gujarati Hindi Kannada Kashmiri Malayalam Marati

CODE Oriya

LANGUAGE

CODE

Punjabi Rajasthani Sindhi Tamil Telugu Urdu Others

9. NATIVE STATE: Please refer item 14 and fill up the State Code. For example, if your Native State is Karnataka it should be written as: 2 3

10. NAME OF PARENT/GUARDIAN: Write the name of your parent or guardian. For example, MR. SUDIR KUMAR SINGH should be written as:

11. ADDRESS FOR CORRESPONDENCE: Write the complete postal address including PIN CODE to which communications to be sent. Also write the telephone number with STD code and e-mail address, if any. For example, the address, MR. RAVI SUNDAR SINGH, S/O SUDIR KUMAR SINGH, NEW No 20, OLD No 23, 2ND CROSS, INDIRA NAGAR, ADAYAR, CHENNAI 600020 ADDRESS FOR CORRESPONDENCE (DO NOT REPEAT NAME)

12. CITY: Fill in your citys name. For example, the city Chennai should be written as:

13. DISTRICT: Fill in your districts name. For example the District Nellore should be written as: N E L L O R E

14. STATE: Refer to the table given below for state codes. For example, the state Tamil Nadu should be written as:

STATE Andhra Pradesh Arunachal Pradesh Assam Bihar Chattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya

CODE Mizoram Nagaland Orissa Punjab Rajasthan Sikkim Tamil Nadu Tripura

STATE

CODE

Uttar Pradesh Uttaranchal West Bengal Andaman and Nicobar Islands (UT) Chandigarh (UT) Dadra and Nagar Haveli (UT) Daman and Diu (UT) Lakshadweep (UT) Puducherry (UT)

15. PINCODE: Fill up with the appropriate 6-digit Pincode. For example, the Pincode 600 020 should be written as:

16. STD CODE: Fill up the STD code in the boxes provided. Use zero when prefixed to the STD code. For example, the STD code for Chennai 044 should be written as:

17. TELEPHONE NUMBER: Fill up your phone number in the boxes provided. For example, the telephone number 42022527 should be written as:

18. MOBILE NUMBER: Fill up your mobile in the boxes provided and do not prefix 0 or leave any blank between numbers. For example, the mobile number 9123456789 should be written as: 9 1 2 3 4 5 6 7 8 9

19. EMAIL ADDRESS: Fill up the email id in CAPITAL letters without blank spaces. For example, the e-mail id ravisundarsingh@gmail.com' should be written as:

20. DETAILS XII AND X STANDARD: Write the school / College, Board / University code, Registration No., Month and year of Passing and aggregate percentage marks obtained in Xth standard / aggregate percentage marks obtained in PCM (Physics-Chemistry-Maths)/ th th PCB (Physics-Chemistry-Biology) in XII std or equivalent examination. In case the XII result has not been published, the marks obtained should be sent on-line and mark sheet should be produced at the time of counseling. (Refer the table below, an example for Board / University code) For example, if you are from Church Park School, Tamil Nadu Board of Higher Secondary Education, passing XIIth standard in May 2011 with Xth standard score of 95%, it should be written as:
SCHOOL EXAM XII X SCHOOL CHURCH PARK CHURCH PARK BOARD (CODE) REGISTRATION NO. MONTH / YEAR OF PASSING % MARK

th

th

Name of Board Andhra Pradesh Board of Intermediate Education Assam Higher Secondary Education Council Bihar Intermediate Education Council Central Board of Secondary Education Chattisgarh Madhyamik Shiksha Mandal Council for the Indian School Certificate Examinations Goa Board of Secondary and Higher Secondary Education Gujarat Secondary and Higher Secondary Education Haryana Board of Education Himachal Pradesh Board of School Education J & K State Board of School Education Jharkhand Academy Council Karnataka Board of Pre-university Education Kerala Board of Public Examinations Madhya Pradesh Board of Secondary Education Maharashtra State Board of Secondary and Higher Secondary Education Manipur Council of Higher Secondary Education Meghalaya Board of Secondary Education Mizoram Board of School Education Nagaland Board of School Education Orissa Council of Higher Secondary Education Punjab School Education Board

Code

Rajasthan Board of Secondary Education Tamil Nadu Board of Higher Secondary Education Tripura Board of Secondary Education U.P . Board of High School & Intermediate Education Uttaranchal Shiksha Evam Pariksha Parishad West Bengal Council of Higher Secondary Education Others 21. DETAILS OF QUALIFYING EXAMINATION FOR UG / PG / PG DIPLOMA PROGRAMS: Write the name of the qualifying examination, College, University, Registration No., Month and year of passing and percentage marks obtained. In case the result has not been pulished, the marks obtained should be produced at the time of counseling. For example, an M.Sc., applicant should give B. Tech, details.
EXAMINATION B.Sc., COLLEGE SRM Arts & Science College UNIVERSITY SRM University REGISTRATION NO. 687347 MONTH / YEAR OF PASSING MAY 2011 AGGREGATE % MARK

22. PARENT / GUARDIAN OCCUPATION: Write the occupation of your parent using the table given below. For example if your parent is in Business, it should be written as:

OCCUPATION GOVERNMENT SERVICES I.A.S I.P .S I.F.S SERVICE CATEGORY Army Air Force Navy Police Judiciary Other Govt. Services PUBLIC SERVICE Minister, Central Govt. Minister, State Govt. MP MLA MLC Member of Local Body

CODE

OCCUPATION PROFESSION Engineer Doctor Chartered Accountant Lawyer Agriculturalist Artist Software Consultant Teacher Self Employed Other Private Sector Business Others

CODE

23. PARENTS INCOME (`):For example, if the parents income is 2,22,000, tick as:
Below 50,000 50,001 to 1,00,000 1,00,001 to 2,00,000 2,00,001 to 4,00,000 Above 4,00,000

24. PROGRAM APPLIED: Tick your preferred program. For example, if an applicant is applying for B.Tech, tick the box as below: GROUP - I B. TECH M. TECH M.B.A. M.C.A.
HEALTH SCIENCES UG

GROUP - II B. ARCH B. DES PGPM

GROUP - III PGPRM M. ARCH HUMANITIES

SCIENCE &

24(a): OPTION FOR ONLINE EXAM (ONLY FOR GROUP 1) If a candidate wishes to appear for online entrance exam, indicate Yes, otherwise indicate No. YES NO

24(b): TEST CITY CENTRE FOR ONLINE EXAM (ONLY FOR GROUP 1) This item is applicable in respect of those programs for which entrance examination is to be held online. If a candidate has opted for online entrance examination in item 23 (a), refer the table given in page no. 6 to choose a test city and write the appropriate code in the space provided. Leave the box unfilled, if not applicable. For example, if an candidate prefers Bangalore as test city it should be written as 1 4 1

24: CHOICE OF ONLINE EXAM SLOT (ONLY FOR GROUP 1) This item is applicable for candidates who have opted for online examination. Choose from the following any one slot for your exam and put a tick in the appropriate box: Date 20.04.2013 20.04.2013 21.04.2013 21.04.2013 Time 9.00 a.m to 11.30 a.m 2.00 p.m to 4.30 p.m 9.00 a.m to 11.30 a.m 2.00 p.m to 4.30 p.m Slot Number 1 2 3 4

For Example, if a candidate chooses 21st April 2013, 9.00 a.m to 11.30 a.m, it should be written as: 1 2 3 4

25. TEST CITY (PAPER-PENCIL EXAM) [ONLY FOR GROUP 1]: Refer to the table given in page 7 for test centre codes. Leave the box unfilled, if not applicable. For example, if an applicant prefers Hyderabad as test city, it should be written as: 3 26. BRANCH / SPECIALIZTION: For the Branch code, refer to the list given in pages 8 to 12. For example, if an applicant is applying for B. Tech with Branch / Specialization Choice 1 as Computer Science and Engineering, Choice 2 as Information Technology and Choice 3 as NIL, it should be written as: 1 0 CHOICE 1 8 1 1 CHOICE 2 3 CHOICE 3

27. PAYMENT OF APPLICATION FEE: For application fee of ` 900/- to be drawn in favour of SRMIST Payable at CHENNAI. DEMAND DRAFT: Fill up the DD number, Amount, Date, Issuing Bank & Branch name. Also, write your name, program applied for and mobile number. on the reverse of the DD. 28. DECLARATION: Applicants and the Parent / Guardian must sign (with date) the declaration to authenticate the information provided by them. Unsigned applications will not be accepted. LAST DATE OF ACCEPTANCE: 15th MARCH, 2013 MAIL THE FILLED APPLICATION ALONG WITH A DD FOR ` 900/- TO
THE DIRECTOR (ADMISSIONS)

SRM UNIVERSITY, SRM NAGAR, KATTANKULATHUR 603 203, KANCHEEPURAM DT. TAMIL NADU, INDIA. E-MAIL: director.admissions@srmuniv.ac.in, TEL: +91-44-27417400, FAX: +91-44-2745 3622 5

CODES OF THE TEST CITY CENTRES FOR ONLINE EXAM (Reference for Item No. 24 b) State Andhra Pradesh Centre Name Guntur Hyderabad Karimnagar Nellore Rajahmundri Tirupathi Vijayawada Vishakhapatnam Warangal Assam Bihar Chandigarh Chattisgarh Gujarat Haryana Jammu & Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharastra New Delhi Orissa Rajasthan Tamilnadu Guwahati Patna Chandigarh Raipur Ahmedabad Faridabad Gurgaon Srinagar Jamshedpur Ranchi Bangalore Ernakulam Kozhikodu Bhopal Indore Mumbai Nagpur New Delhi Bhubaneshwar Jaipur Kota Chennai Chennai - KTR Coimbatore Madurai Tiruchirapalli Vellore Uttar Pradesh Allahabad Ghaziabad Gorakpur Kanpur Lucknow Meerut Noida Varanasi Uttaranchal West Bengal Dehra Dun Kolkata Centre Code 102 103 104 106 107 108 109 110 111 114 119 121 124 126 131 132 136 139 140 141 143 145 148 150 152 153 155 156 161 163 166 167 169 175 180 183 184 187 188 190 191 192 193 194 195 197

CODES OF THE TEST CITY CENTRES (Reference for Item No. 25)
STATE CENTRE NAME CODE STATE CENTRE NAME CODE STATE CENTRE NAME CODE

Andaman & Nicobar

Shimla Port Blair 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 Tamil Nadu Puducherry Punjab Rajasthan New Delhi Orissa Maharshtra Kerala Karnataka Jharkhand
Jammu & Kashmir Jammu

134 135 136 137 138 139 140 141 142 143 144 145

Chidambaram Coimbatore Cuddalore Dindugal Erode Krishnagiri Kumbakonam Madurai Nagercoil Namakkal Salem Thanjavur Tiruchirapalli Tirunelveli Tiruppur Vellore Uttar Pradesh Allahabad Bareilly Faizabad Ghaziabad Gorakpur Jhansi Kanpur Lucknow Meerut Noida Varanasi Uttaranchal West Bengal Dehra Dun Durgapur Kolkata Siliguri

168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198

Andhra Pradesh Guntur Hyderabad / Secunderabad Karimnagar Karnool Nellore Rajahmundri Thirupathi Vijayawada Visakhapatnam Warangal Arunachal Pradesh Assam Itanagar Dibrugarh Guwahati Bihar Bhagalpur Darbhanga Gaya Muzaffarpur Patna Samastipur Chandigarh Chattisgarh Chandigarh Bilaspur Korba Raipur Goa Gujarat Panaji Ahmedabad Rajkot Surat Vadodara Haryana Bahadurgarh Faridabad Gurgaon
Himachal Pradesh Dharamsala

Srinagar
Bokaro Steel City

Dhanbad Jamshedpur Ranchi Bangalore Hubli Ernakulam Kottayam Kozhikodu

Thiruvananthapuram 146

Thrissur Madhya Pradesh Bhopal Gwalior Indore Katni Mumbai Nagpur Pune New Delhi Bhubaneswar Raurkela Puducherry Jalandhar Bikaner Jaipur Jodhpur Kota Udaipur Attur(Salem) Chennai Chennai Kattankulathur

147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167

(Reference for Item No. 26)

BRANCH / SPECIALIZATION CODE ENGINEERING & TECHNOLOGY MANAGEMENT MEDICINE & HEALTH SCIENCES SCIENCE & HUMANITIES.
BRANCH / SPECIALIZATION B. TECH (duration 4 years) Aerospace Engineering Automobile Engineering Bioinformatics Biomedical Engineering Biotechnology Chemical Engineering Civil Engineering Computer Science & Engineering Electronics & Communication Engineering Electrical & Electronics Engineering Electronics & Instrumentation Engineering Genetic Engineering Information Technology Information & Telecommunication Engineering Instrumentation & Control Engineering Mechanical Engineering Mechatronics Nanotechnology Software Engineering M.Tech (duration 2 years) Biomedical Engineering Biotechnology Bioinformatics Chemical Engineering Cloud Computing Communication Systems Computer Aided Design 2 2 2 2 2 2 2 0 0 0 0 0 0 0 1 2 3 4 5 6 7 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9

BRANCH / SPECIALIZATION Computer Integrated Manufacturing Computer Science & Engineering Construction Engineering & Management Database Systems Electronics & Control Engineering Embedded System Technology Environmental Engineering Food and Nutritional Biotechnology Food Safety and Quality Management Genetic Engineering Geo Technical Engineering Information Technology Information Security and Computer Forensics Knowledge Engineering Multimedia Technology Nanotechnology Power Electronics & Drives Power Systems Remote Sensing & GIS Robotics Software Engineering Solar Energy Structural Engineering Telecommunication Networks VLSI Design Water Resources & Management MBA (Master of Business Administration) (duration 2 years) MCA (Master of Computer Applications) (duration 3 years) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 5 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 2

BRANCH / SPECIALIZATION HEALTH SCIENCES BDS (duration 4 years + 1 year internship training) B.Sc Nursing (duration 4 years) BPT (duration 4 years+6 month internship) BOT (duration 4 years+6 month internship) B.Pharm (duration 4 years) BASLP (duration 4 years) B.Optom (duration 4 years) B.Sc Radiology & Imaging Technology (duration 4 years) B.Sc Renal Dialysis Technology (duration 3 years) B.Sc MLT (duration 3 years) Pharm.D (duration 6 years) Group 2 B.Arch. (Bachelor of Architecture) (duration 5 years) Group 3 B.Des. (Interior Design) (duration 4 years) B.B.A (duration 3 years) PGPM (Postgraduate Program in Management) (duration one year) PGPRM (Postgraduate Program in Retail Management) (duration one year) M. Arch. (Architectural Design) (duration 2 years) Health Sciences BMRS (duration 2 years) P .B.B.Sc Nursing (duration 2 years) Diploma Courses Diploma in Optometry (duration 2 years) Diploma in Medical Laboratory Technology (duration 2 years) Diploma in Medical Record Science (duration one year) 3 3 1 1 4 5 3 3 1 1 2 3 1 2 2 5 5 5 2 1 3 1 5 1 3 3 3 3 3 3 3 3 0 0 0 0 0 0 0 0 1 2 3 4 5 6 7 8

3 3

1 1

0 1

10

BRANCH / SPECIALIZATION SCIENCE & HUMANITIES B.Sc (duration 3 years) Biotechnology Computer Science Information Technology Hotel & Catering Management Visual Communication Film Technology Mathematics Physics Chemistry B.C.A (duration 3 years) B.A Journalism & Mass Communication (duration 3 years) B.Com (duration 3 years) General Corporate Secretaryship Accounting & Finance Information & System Management B.Ed Diploma Program Hotel Management (duration 3 years) Teacher Education (duration 2 years) Film Acting (duration 1 year) M.A (duration 2 years) Political Science Public Administration International Relations Journalism and Mass Communication 5 5 5 5 2 2 2 2 0 1 2 3 5 5 5 1 1 1 7 8 9 5 5 5 5 5 1 1 1 1 1 2 3 4 5 6 5 5 5 5 5 5 5 5 5 5 5 0 0 0 0 0 0 0 0 0 1 1 1 2 3 4 5 6 7 8 9 0 1

11

BRANCH / SPECIALIZATION M.Sc (duration 2 years) Biotechnology Information Technology Hotel & Catering Management Visual Communication Mathematics Physics Chemistry M.Ed (duration 1 year) PG Diploma (duration 1 year) Journalism 5 3 3 5 5 5 5 5 5 5 5 2 2 2 2 2 2 3 3 4 5 6 7 8 9 0 2

12