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Application for admission to B.E. 2013 B. Arch 2013

Based on Overall AIR in JEE-MAIN 2013 through Institutional Counselling for BIT Mesra

Please use one form to apply for only ONE programme either B.E. or B. Arch

PLEASE WRITE IN CAPITAL LETTERS, PUT NUMBERS OR TICK (

) THE BOXES AS REQUIRED

1. Full Name of Candidate: ______________________________________________

2. Fathers Name: _____________________________________________________

3. Mothers Name:_____________________________________________________

4. Date of Birth: in dd/mm/yy format __________/__________ /__________

5. Age on 1/10/2013__________years __________months __________days

6. Sex: Male Female

7. JEE-MAIN 2013 Roll No:_______________________

8. JEE-MAIN 2013 Application No _____________________

9. Overall AIR in JEE-MAIN 2013___________10. State of Eligibility _______________

11. Category: [Tick whatever is applicable]

(a) GEN (b) SC (c) ST (d) PH12. Preferences of branch (see notification)

(a)_______________(b)_________________(c)_________________

13. Educational record:

Examination Board /

University

Year of

passing

Percentage

of Marks#

No of

Attempts$

Subjects**

Class 10 /Matriculation exam

Class 12 / I. Sc. / or

equivalent (specify)

14. School/College from where you have completed Class 12 / Qualifying ExaminationQUALIFICATION NAME AND ADDRESS OF SCHOOL / COLLEGE

WITH TELEPHONE NUMBERSTATE

Instructions: Please ensure that you fulfill all the eligibility criteria before filling the formPLEASE DO NOT WRITE MR. / SHRI / MISS/ / MS/ MRS. / SMT IN SPACE FOR NAME

Enclose photocopies of marksheets of Class 10, Class 12, Admit card and Score card of JEE-Main2013 and Caste / Special Category certificates. Write your Name, programme applied for andtelephone number, on the back of these papers.$ Write 1 if cleared in one attempt, etc** Use abbreviations such as ENG, CHEM, MATH, PHYS, BIO, etc

BIRLA INSTITUTE OF TECHNOLOGY

(Deemed University)

Mesra, Ranchi 835 215, Jharkhand

Application Form For B.E. / B. Arch 2013at BIT Mesra

SESSION 2013 2014

For office use only

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15. Address for communication including your full name:

16. Permanent Address: ________________________________________________

________________________________City_______________ Pin code____________

STD Code _______Telephone Number____________ Mobile ____________________

E-mail id: ___________________________________________________________

17. Details of Demand Draft attached for Rs.2,500/-(General) and Rs.1,500/- (SC/STcandidates) in favour of Birla Institute of Technology, payable at Ranchi:

Demand Draft No.___________________________ Date of Issue: _________________

Issuing Branch_________________________________ City ______________________

18. Declaration: I hereby declare that all the information given by me in this application is

true and correct to the best of my knowledge and belief. I also note that if any of the abovestatements are found to be incorrect or false or any significant information or particularshave been suppressed or omitted there from, I am liable to be disqualified. If selected myadmission will be liable to be cancelled without notice or compensation in lieu of notice.

I hereby permit / do not permit (delete one) the Institute to use, display or transfer any of thedetails furnished by me in this form for any other purpose, except for complying with theadmission formalities.

Signature of Candidate:______________________Date: __________________

Countersigned by Parent:______________________Date: __________________

Enclosures required:Photocopies of following certificates must be attached to application form:1. Admit Card & Rank Card of JEE-MAIN 20132. Pass Certificate & Mark Sheet of Class 103. Mark Sheet of Class 124. Caste Certificate (if applicable) in proper format and issued by appropriate authority of rank not less

than SDO

5. PH Category Certificate (if applicable) issued by appropriate authority, in JEE-MAIN 2013 / CSABformat clearly specifying that candidate is capable of carrying out all activities related to theory andpractical work including workshop and drawing in the Architecture / Engineering courses without anyspecial concessions and exemptions

6. School Leaving Certificate and Migration Certificate_________________________________________________________________________________

For office use only

Eligible Not Eligible

In case ineligible, please specify reasons: _____________________________________________

Signature of verifying Officer/ Staff

Address for communication (should be valid till Dec 2013)

Name: ___________________________________________

_________________________________________________

_________________________________________________

City_________________________ Pin code_____________

STD Code________ Telephone Number________________

Mobile __________________________________________

Paste recent colourphotograph here

Do not get thephotograph attested

Si nature