An ISO 9001:2008 Certified Institution

MSEC

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Navarathna Agrahara, Sadahalli Post, Off Bangalore International Airport Road, Bangalore - 562 110. Tel. : +91 80 3252 9939, 3252 9575, 2846 7090 / 91, Fax : +91 80 2846 7092 Email : principal@msec.ac.in www.msec.ac.in

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APPLICATION FOR ADMISSION TO B.E. COURSE

To, The Principal M.S. Engineering College Navarathna Agrahara, Sadahalli Post, Off Bangalore International Airport Road, Bangalore - 562 110

APPLICATION FORM No.

Affix the Recent Passport Photograph

Note : Please

tick wherever required / Use only Block Letters / Indicate NA, if not applicable.

Name of the Candidate (As in the Qualifying Examination Certificate) Date of Birth E-mail ID (Student) Mother Tongue Religion b) Region Native Place a) Permanent Address Caste Urban Village/ Town District Category Rural Taluk State b) Local Address Nationality DD MM Y Y Y Y Sex Male Female

Pin code : Phone: Fathers Name Mothers Name Guardians Name (If Parents are not alive) Annual Income of Parent / Guardian E-mail : (Parent/Guardian) Name & Cell No. of a blood Relation (For Contact in Case of Emergency) Special Category Status Seat Type Admission Quota KEA Admn. Order No. / Comed -K TAT No. & Date of issue Karnataka or Non-Karnataka Entrance RANK Allotted Branch Branch Preferred (MGT. Quota Only) 1) KEA NCC Sports Comed K Mobile :

Pin code : Phone: Mobile :

Occupation

Mobile : Scouts & Guides MGT Defence Ex-Defence GOI DD FN MM Physically disabled Others(Specify) YYYY

KEA

Comed K

AIEEE

2)

3)

* KEA - Karnataka Examination Authority,

MGT-Management Quota, FN - Foreign Nationals GOI - Government of India

Name of Qualifying Examination Passed the Exam State

Page 2 Name of the Board Month & Year of Passing 2. Mathematics 3.

Reg. No.

12 a) Marks obtained in
Optional Subjects

1. Physics

Total Marks in 3 Subjects

Percentage

b) Marks obtained in Diploma

I/II Sem Receipt No.

III/IVSem

V/VI Sem Date MM A+

Total V/VI Sem

Percentage

13 Miscellaneous Fee Details

Blood Group

DD No. DD

Amount in Rs. YYYY AB+ ABO+ O-

A+

A-

B+

B-

14 Any Physical Defect

Any Chronic Ailment Sports(Specify) Level of Participation National State Others (Specify)

15

Cultural Activities (Specify) Level of Participation National NCC State Others (Specify) Scouts & Guides
NSS

16 Other Activities

Others (Specify)

Have you submitted the following Documents with 3 sets of xerox copies ? (Students admitted under Management Quota the Original Documents should be submitted as follows :
I. ii. iii. KEA / Comed K / AIEEE Allottment Order 12th Standard Marks Card Transfer Certificate Caste Certificate (in case of SC / ST & other Caste) Eligibility Certificate from VTU in case of Non - Karnataka Students Transfer Certificate for having resided in Karnataka for a minimum period of seven years at any time. Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

17

iv. v. vi.

vii. Migration Certificate in case of Non-Karnataka Students viii. Eligibility Certificate & Other Supporting Documents for NRI Students ix. Four passport & Stamp size photographs with name

DECLARATION BY THE CANDIDATE

I) I Declare that the above said statement / particulars are true and correct to the best of my knowledge and belief. In case the above said statement / particulars are found incorrect this application for the seat is liable to be rejected and forfeited.

2) I undertake that as long as I am a student of this college, I will do nothing unworthy of a student of the college either inside or outside or any thing that will interfere with its orderly working and discipline. 3) I am aware that the management has full authority to expel me for not showing interest in studies, misbehavior or continuous failures. 4) Original certificate should be produced for verification at any time required by the College and the University.
Place : Bangalore : Signature of the Candidate

DECLARATION BY THE PARENT GUARDIAN

I declare that I shall pay the tuition and other payable to the institution under the rules frame from time to time by the management of the College. Under no circumstances, I will claim refund of the tuition and other fees against cancellation of admission. I undertake to pay the prescribed fees for the entire course in case of cancellations of admission in the middle of the course

Place : Bangalore : Signature of the Parent /Guardian