ADVANCE REGISTRATION FORM – B.TECH. 1st YEAR Application No.………………
MORADABAD INSTITUTE OF TECHNOLOGY APPLICATION FOR ADVANCE REGISTRATION FOR ADMISSION TO 1st YEAR OF B.TECH. DEGREE COURSE FOR THE SESSION 2013-2014 1.
Name of the Applicant
…………………………………………………………..
2.
Father’s Name
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3.
Mother’s Name
…………………………………………………………..
4.
Permanent Resident of & Its Address
………………………………………………………….. ………………………………………………………….. …………………………………………………………..
5.
Present Address for communication
………………………………………………………….. ………………………………………………………….. …………………………………………………………..
6.
Telephone Nos..
…………………………………………………………..
7.
Mobile Nos.
…………………………………………………………..
8.
Email ID
…………………………………………………………..
9.
Date of Birth
…………………………………………………………..
10.
Gender
…………………………………………………………..
11.
Category (Gen/OBC/SC/ST)
…………………………………………………………..
(Self Attested Copy of Caste Certificate to be attached for OBC/SC/ST)
12.
Appeared in UPSEE-2013
Roll No. …………….. Marks…………. Rank …………....
13.
Appeared in JEE Main-2013
Roll No. …………….. Marks…………. Rank …..………..
14.
Marks in PCM in 10 + 2
Marks
%
Examination (Self Attested Copy-
Mathematics
……….
……….
of mark sheet to be attached)
Physics
……….
……….
……….
……….
Chemistry/Biology/ Bio Technology
Total ………… Percentage …………….. 15. Class
10th 10+2
Academic Details :Roll No.
Subject
Board/ University
Max. Marks
Marks Obtained
Year
Percentage
16.
Parent’s Occupation
…………………………………………………………..
17.
Parent’s Annual Income
…………………………………………………………..
18.
If 10+2 examination passed from an institution outside of U.P then is Domicile Certificate of Father/Mother Available ? ……………………………………………. (If Yes, Self Attested Domicile Certificate to be attached) Branches requested in order of (i) ………………. (vi) ……………….. preference (ii) ………………. (vii) ……………….. (iii) ………………. (viii) ……………….. (iv) ………………. (ix) ……………….. (v) ………………. Registration Amount Rs. 10,000/- deposited vide (Bank details) ………………………… ………………………………. DD No. ……………….... dated …………………. and Processing Charges Rs. 1,000/deposited vide (Bank details) ………………………… ………………………………. DD No. ……………….... dated …………………. both in favour of Moradabad Institute of Technology, Moradabad.
19.
20.
D E C L A R A T I O N 1. 2.
3.
4. 5.
I hereby declare that I am applying for admission with the clear understanding that :Registration is not a guarantee for admission. Admission will be offered in the institute in different branches on the basis of merit in the UPSEE2013/JEE-2013/ qualifying subjects in 10+2 examination, in that order / as per the directives of the UPSEE-2013 in this regard. The details of Rs. 11,000/- being deposited are as under :(a) Rs. 10,000/- is the Registration amount which will be adjusted against the fees incase admission is taken in this Institute in the year 2013-2014. Rs. 10,000/- will be refunded if admission to any one of the branches applied for is not offered. It may take about two weeks after the admission process is over. (b) Rs. 1,000/- is the Processing Amount and is non-refundable and non adjustable. The registration amount will be forfeited, if admission offered in any of the branches applied for is not accepted by the candidate. Request for cancellation of registration and subsequent refund of Rs. 10,000/- may not be considered in the intervening period between registration and admission.
Signature of father/Guardian Signature of Candidate as a token of having agreed with the Name ………………………….. declaration made by his son/ward Date ………………………….. Name ……………………………… Date ……………………………… Enclosures : 1. Photocopy of Mark sheet of 10+2/Intermediate Examination. 2. Demand Drafts bearing No. …………………. dated …………... for Rs. 10,000/(Ten Thousand Only) and DD No. ….…………….. dated ……………….. for Rs. 1,000/- (Rupees one thousand only) both in favour of Moradabad Institute of Technology, payable at Moradabad. 3. Caste Certificate (If Applicable) 4. Domicile Certificate (If Applicable) 5. Rank proof of UPSEE-2013/JEE Main-2013, as applicable.
