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INDIAN INSTITUTE OF ENGINEERING SCIENCE AND TECHNOLOGY, SHIBPUR

HOWRAH - 711103, WEST BENGAL

APPLICATION FOR ADMISSION TO UG (DUAL DEGREE)/B-Arch/PG(M-Tech/M.Sc.),MTRP
(Use

mark where applicable)

MTRP

M-Tech.

Bachelor of Architecture

Dual Degree

ID NO. Allotted to the candidate

M.Sc.

For M-Tech: (Through GATE/NET/SLET)

( To be filled by the office)

MBA

For MBA: (CAT/CMAT/XAT with score)

GATE/NET Reg. No.

For Under Graduate Course:(Through JEE MAINS only)
JEE MAINS

(50%):

Rank

WB Domicile (50%):

Rank

GATE/NET Score
GATE/NET %

GATE Score valid up to
Month

Year

Branch: ...........................................................................................................................................

Or

Branch: .........................................................................................................................

Specialisation: ..............................................................................................................................
For M-Sc.:
IIEST M-Sc. Rank
(50% from CCMN & 50% from IIEST) CCMN Rank

Category of Candidature for all courses:
GENERAL

SCHEDULED CASTE

FOREIGN QUOTA

DEFENCE QUOTA

Branch: ...........................................................................................................................................
SCHEDULED TRIBE
OBC - A
PHYSICALLY DISABLED (PWD)
ANY OTHER
STATE NOMINEE
OBC - B
(Please state)

Caste Certificate issued by with No. & date: ...................................................................................................................................................
Name of the candidate (In CAPITAL LETTERS) :
Mr.

Ms.

Date of Birth:

Other

Month

Date

Year

Affix
Stamp size
colour photograph

First Name
Middle Name

(Self attested)

Surname
email address: ................................................................................................................................................................................................................................
Height
Female
Other
Weight
Mt./Ft.
Cm./inch
Adhar Card no.
Kg Male
Blood Group

Personal Identification Mark .......................................................................................................................................
Nationality .................................................... Religion: Hindu

Muslim

Christian

Sikh

Buddhist

Jain

Others

Name of the Guardian:
Tel.no.

Relation with the candidate
Address for communication:

Urban

Present / Permanent Address:

Flat no.

Rural

Nearest Rly. Station
Block no.

Village/City

Road/Street

Post Office
District

Police Station

Mobile no.

PIN
Country

State

Father’s Name

Mother’s Name

Occupation

Occupation

Address

Address

PIN

Tel.no.

PIN
Rs.2,50,000 to Rs.5,00,000

Family Income: Less than Rs.2,50,000
Educational Qualifications:
Name of the Examinations

Tel.no.

Last Examination Passed
Name of the Board

Rs.5,00,000 and above

Last Examination appeared
Year of passing

Total obtained Marks with Percentage

Remarks

In case of emergency whom to contact (Local Guardian):
Mobile no:

Mr./Mrs.
Checked & Verified with Signature:

Admission department: ..........................................................

Date: .................................................

. 4.... 1................ Department .. obscene gesture to anybody..... drugs.... that I shall not commit any act that would bring disrepute to the Institute and shall not be involved in any activities that would tarnish the image of the Institute................................................. I shall not keep any bike/schooter in the hostel............................................................... for any offence committed on my part in violation of the rules of the Institute. 7............................ 2..... ............... Neither I would possess any extra keys of the hostel gate......... Year ..................................... I have gone through the “Code of conduct for Students” of this Institute and shall abide by it in course of my study at this Institute..... narcotics of any form and display and view any obscene graphics / photographs/videographs within the Institute premises................................. I shall not enter into Oval or Lord’s ground after dusk.......... I shall not use mike/sound system with loudspeaker inside the campus................................ as otherwise I may not be permitted to appear for Institute and Semester Examinations........................................... I must attend classes regularly as per routine so as maintain attendance above 75% in each the Theoretical and Sessional subjects........... I shall not use alcohol............................................. 11......... that my admission will be liable to stand cancelled if any of the aforesaid information is found to be untrue.................. that I am fully aware of the Act regarding participation in ragging and of the punishment that may be meted out to me if I am found guilty of ragging and that I am liable to be punished in terms of the said Act........................I shall not enter a boy’s hostel at any point of time............................................ I shall not stay outside Hostel/Hall after 10........ 10. Name of the student ...................... 6.....................30p....... that I shall scrupulously abide by the standing rules of the Institute...... and 4) that I am fully aware of the Act regarding participation in ragging and of the punishment that may be meted out to my ward in terms of the said Act if he/she found guilty of ragging at any time during his/her studentship in this Institute. Academic session in which admitted ................. Date: ............................. I will refrain from using foul word / vulgar expression..... I shall carry Identity Card at all times within the Institute Premises........... causing any kind of noise pollution /physical / mental abuse to anybody inside the campus............................... Course of study .. I do hereby declare: Signature of the candidate .................. Counter signed by the Guardian with date Signature of the student ........... 3..... that I shall do everything in my power to enhance the reputation and honour of the Institute.... Signature of the verifying official Admit * ....................... that I shall be liable to face punishment..............Details of Institution last attended: Name of the Institution ......................... b........................................ DECLARATION BY THE PARENT(S) / GUARDIAN 1) that the information given by the candidate are true to the best of my knowledge and belief................ Shibpur Howrah-711103 Affix Stamp size colour photograph Sir................................. including expulsion from the Institute............................. a..... and that my admission shall be treated as provisional till production of my mark sheet for the 10+2/UG Examination......... 5......(For Female Students).................. I shall refrain myself from swimming and bathing in the river Hooghly and Ponds/Jheels inside and around the campus... Without prior permission from respective superintendent.................................. DECLARATION BY THE CANDIDATE To The Dean (Academic) Indian Institute of Engineering Science & Technology..I shall not enter a girl’s hostel at any point of time........ I shall not involve myself in the act of ragging....................................................... Board/University ................................................. Declaration by the candidate I do hereby declare: 1) 2) 3) 4) 5) 6) 7) 8) that the information given above are true to the best of my knowledge and belief........... To be filled in by the Office Certified that the particulars given by the candidate have been verified with ................ 9............................. 3) that I agree to cooperate with the Institute authority in adopting corrective measures in case the candidate does not abide by the rules of the Institute and becomes liable to be punished on being found guilty of violating the rules...... 12. 8...... Name in full (in BLOCK LETTER) ...........................(For Male Students).............. bursting of firecrackers.... I shall not smoke in any of the Institute building as per judgement of the Hon’ble Supreme Court............. Relationship with Candidate .................................. Signature of the Parent/Guardian .................m..... Signature of the competent authority .... 13..................... Date: ......................................... 2) that I shall be responsible for payment of Institute dues at the prescribed rates on a regular basis. I shall not indulge in any kind of hooliganism.