ENGINEERING & TECHNOLOGY

Application Number
Application Submitted on:

3633901
07-Mar-2013

ADMISSION 2013

1.SIGNATURE 2. NAME OF THE APPLICANT PRAKASH 3. GENDER 4. RELIGION Hinduism Male Female 7. DATE OF BIRTH SC ST 27-Jun-1988 5.NATIONALITY Indian

6.COMMUNITY General/OC OBC/BC/MBC

SRM UNIVERSITY

8. MOTHER TONGUE Hindi 14

9.NATIVE STATE Bihar 14

10.NAME OF PARENT/GUARDIAN ASHOK KUMAR SINGH

11. ADDRESS FOR CORRESPONDANCE(DO NOT REPEAT NAME) House No 67 A N Path,Alpana Market Patliputra

12. CITY 13. DISTRICT Patna 16.STD CODE 0612

Patna 14.STATE Bihar 14 17.TELEPHONE NUMBER 2273467 15.PINCODE 800013 18.MOBILE NUMBER 9873925313

19. EMAIL ADDRESS praks2706@gmail.com

Application Printed Date: 07-Mar-2013

Page 1 of 2

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20.DETAILS Xth AND XIIth STANDARDS SCHOOL EXAM SCHOOL BOARD/ UNIVERSITY

PASSED REGISTRATION NUMBER

APPEARING MONTH/YEAR % OF MARKS

XII standard
Anugrah Narayan College Patna

Bihar Intermediate Education counsil 13

Not Required

01/06/2005

50.01

X standard
Not Required Not required Not Required Not Required 66.00

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

ADMISSION 2013

PASSED QUALIFYING EXAM COLLEGE UNIVERSITY REGISTRATION NUMBER

APPEARING MONTH/YEAR OF AGGREGATE % OF MARKS PASSING

UG/PG/DIPLOMA

R.P. Sharma Institute of Technology, Raghunath Complex

Magadh University Bodh Gaya

74.17

22.PARENT'S OCCUPATION Business 60 24. PROGRAM APPLIED GROUP-I B.Tech M.Tech MBA GROUP-II B.Arch B.Des

23.PARENT'S INCOME (RS) 2,00,001 - 4,00,000 GROUP-I GROUP-III PGPM PGPRM M.ARCH B.B.A

SRM UNIVERSITY

24(a).OPTION FOR ONLINE EXAM YES NO

24(b).OPTION FOR PAPER/PENCIL EXAM YES NO

25.CHOICE OF ONLINE EXAM SLOT(ONLY FOR GROUP I) Slot 4 (21/04/2013 2.00 p.m to 4.30 p.m) 27. BRANCH/SPECIALIZATION 1). 220-M.Tech.-Information Security and Computer 2). 209-M.Tech.-Computer Science and Engineering 3). 219-M.Tech.-Information Technology 28.DECLARATION

26.TEST CITY CENTRE New Delhi 155

I hereby declare that I have carefully read the instructions and particulars supplied to me 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 counselling and admission will not be claimed back under any circumstances.
Payment TXN No: Payment Status: 201303073284681 Successful 07-Mar-2013

SIGNATURE OF APPLICANT
VALID FOR THE ACADEMIC YEAR 2013-2014 ONLY
Application Printed Date: 07-Mar-2013 Page 2 of 2

DATE: