(An lnstitution of National lmportance under MHRD, Govt of lndia)

Ashok Rajpath, Patna- 800 005 (B-ihar)-^Phone No. 0612 - 26i0t31, 2370843, 2371930, 2371?15, 23727t5 Ext No'108'

National Institute of Technology Patna

(Academic section)

Datc- \2.122019Ref:- 580 IAaad. I\9-20

durins the session 2019-2020

with refeTence to notice no.511/Acad. /19-20 dated 06/ll20l9 regarding admission to Ph D

programme and the List(s) of provisionally selected candidates against the interview held on 04$

b."-"mb", 2019, the provisionally selected candidates are hereby informed that they should

rcporl on l/ Decemhet 20tg dt 10:00 AM in the rcspective depo ment lor completlo" o!

a dml ss ion fo rma lil i es.

. The candidates are required to bring following original documents for verification at the time of

admission:

1. Higlr School Certificate2, Mark sheets of all examinations from 1Orh onward including qualifing exarnination

3. Degree of all qualilying examination

4. Character certificate issued by the llead ofthe institution last attended/ from employer

5. Certificate of sponsorship (if applicable)'

6. Affidavit with respect to Gap year (i.e' teason for discontinuity between passing year

ofqualifying examination and year ofadmission to Ph D )

7. Affidavit by the student regarding anti-ragging

8. Affidavit by the parent/guardian regarding anti-ragging

9. Undertaking on non-judical stamp paper ofRs 100/- regarding refund ofscholarship in the

case of withdrawing/ leaving the progamme without completion of course' (ifapplicable)

10. Medical Certificate in the prescribed lormat issued from the registered Medical

Practitioners.

I l. Passport size Photographs (4 Nos)

12. Proof of Payment of admission fee

13. No Objection Certificate (NOC) from the employer, ifapplicable

14. GATENET score card (if applicable)

I5. Valid caste/categoly certificate (if applicable)

. One set of Self attested copies of all documents listed above'

Copy to:-01. All HoDs

website

hyDcrlinl( proYidcd on institutc's wcbsite and bri[g tht hard coDv of thc I'ecciDt as a

proof of oavment made.

Classes of newly admitted students will commence from l Sth December 20 t9'

02. PI (PG) 03. PI (MlS & Web Services): with a request to upload the on Institue's

04. A.R. (AlC) 05. A.R. (Acad.) 06. Secy. to Director 07' PA to Registrar

12.t--

3

NATIONAL INSTTTUTE OF TEC!-INOLC)GY PATNA(An lnstitLrtion of National lrnportance under Mt-tRD, (lovt. o{ tndi=)

Ashok Rajpath, Patna - BOOOO5 (BIHAR)Application form for Admission to

B. Tech./ B. Arch./ M.Sc / M. Tech./ MIIRp/ Dual Degree 7

Rolr tlo. tLe= tranf ,to,ir.ttj,, i rr"il e. ^u"

,,c-.r,CCiIT l3N, PAN o. lor l,{ester':, progfam and

,_j::'i:!.1!rolgh (Setecrlon aLrinority dcra!ts)

Nc. Jor instii\rle le,iei a,:riissioi / Seleclion

Name of candiCais il fuii

las rct 10h C.rnioate)

ilatheis Name

Mothel s l'laile

Guardian's name in full (ilrather is not alive)

Date of Birth (dd-nnm-yy)/ Sex

Occupation of Parenis

Parents lncome per annurn from all sources

Organization where lather/ Mother js

working or Guardian (iifalher is notalive)

Correspondence Address

Pin Code:

-_.-_*_]lMale/ [emale

Ph. D. Tirne / Partlnstitute Roll No.(la be assigned by Receiving affice)

PHOTOGRAPH

Aff ix recent passpo( sizephotograph

AndPut your sionaturo in box provided

iBlow Lhis space inBlack Jell Pen

To be llM W ko caddate k Nsh$ own handwiling in Capilal ledes except signdue

Detai/s of Fee Mode of Payrnent AmountPaid to CCMT / J}$AA I CSAB

Paid to NIT Patna

Total

AlttE/GATS NET Exam and Year CAIEAORY (Pd I na*)Selection Exam RollNo 0P/ GeneraiSelection Exam Rank (All lndia) 0BcSelection Exam Score (marks) SC

Selection Exam Subiecl ST

Qualitying Exami Degree and Branch PH

I(eslden! ol siaic: Spons ciealtstood Gt-ortp AaChaai'No

URP/|)D I, Ph. D[ ] insiitute

Reltg'6n Caste

Admission/ Selection Details for I

Selec|on txamtnaiion Aope2rgl 6,u1 7

Ptogran: i B.Tec./ B. ArchiW,Sc Lyrrgrntmnark) i JEt (l,4alis) GAi

l'lame of candidale in Devnagari (Hi1di)

Phone No. (witn Srn CoOell I/]oOG--No

Page-10f3

Finai allotted Branchi DeDartir,enU Specialization

Master's Degreel

Declaration of the Candidate:

Son/ Daughter of Sri

!-ull lliE:iarure of lire Ui:id;lat. in [ngiish

Full Signalure of Falher / Guardian

Academic Details;

SGPA/ CGPA/ o/o Marks:

Bachelor's Degree:

Declarati.n Ofthe Father / G'ardian: C anddates nE subnit tho der,u,",,on ,, ,"*r, cii**i,**i**r[ u[ffiatet dfi ssbn il F6ther/ Guardian is ngl availabte at lhe iifl1e cl l',mi;sion

a) lnfoimation fumished above are correcl and in case any ol the inlormatiDn is io nd fals-o or f^r6cd ai inv $.6^ ^r -,,d0, nrss,o4 lo ar,o/ , , stay i,r t.te inr,t1r13 .

, 5-; ; ." 1, .',,3

1 1 10 los€ .:.17 :andt.alJle i",. . "i.;., , hJ p,'"gr;; i;1or e):ou sto- fism lite tnstit-le il adn tted dno (, t: tur hpDroojtalc ugr. *,0- --

b) ln the evenl.of nry being a'hitted ic this lnstilirtion, I shall aDide by ati the rules and reguta.ons oi the insi,rut€ andthe Univ-^6ity, mncerned. l

i .) I h3ve luhqled mv 0ualfols-e&tr[drqr_p_a$rry-seddcalcrd[X]&uplis4trg4 foon. oRI I wili srrb'1it my qlarur-e&Er4rQapasiinu cerri'/.care hy the due daie .grfcLDlqllElollf eise my

i adnrission shaltstand Dancelled.

---1fr,lr rJffi,l ever is tnt 3pplicable)

t-_t-==i Pi:ce: I

Page*2of3

Permanent Ad dress

Fin Code:

(Name) declare lhat in the event ot Sri/Smf./ Uisr__-...,.......... ..............being admjtted to this lnstitulion I shall be responsib,e for his / her mnduct.and,hdA,trL6 t^undertake io pav aI his/ her rnstirute, Hoster, r\ress and other dues regurarjy tifl ihc compretjon of hjs / ll.r r;r;.-;;;

certil/ that the lnlormation furnished by hin/ her are correci.

Name ol the candidate in fullRo/i l,lo. (to be assigned by

Recpiving oftice)

L Please verily the Self aftested Photocopies of following:. (as applicable)

(r) CSAB/ CCN.fi Reporung Letter and Allotment Letter

(ii) JEE (Mains)GATE/ NET Rank Card / Score Card

(iir) Certificate of Category 0BC/ SC / ST, ii applicable, lssued by the competenl autholity

(iv) lncome Celtitlcate for OBC Candidates for claim with respeclto Non creamy Layer issued by

competent authority/ as peI directive of the MHRD. (lf seal allatted in OBC caleaoN)

(v) Certifcate for Person with Disabililles/ Physically handicapped

(vi) Class X (High School) Board Certificate as prooi of Date of Birth

(vii) Maticulation (1oih)) Marks Sheet 'v

(viii) Qualifying Examination Marks Sheeu Grade Catd (Strike oul whichever is nol aoplicahle)

lntermediate (12$ ) Marks Sheet

B. Tech/ B.E./ B. Sc. Enggi 8. Arch.

lV. Tech./ M. E./ M. Sc. Engg./ M Arch.

Bachelois Degree in Science/' Humanitres/ gocial Science/ [,4anagemenl etc ,Masteis Degree in Compuler application Science/ Humanities/ Social Science/ N'lanagement

elc.

(ix) Qualifying Examination passing certillcate (as applicable {or the program). /n case ii ls nolbeing submitted then undertaking for subnissio) by due dale fixed by JaSANCSAB/ CCMT.

(x)

--:txr)

Affidavlt with respect to cap year (i.e, reason fr,r Ois;onirnuitv Uctweei passinglear ofqualiFTing examination and yea ol admission to B. Tech/ B. Archi Master s program.)

Cedificale ol Sponsorship, if applicabLe, lssueri oy ihe coripetent autiloriiy

(,.<ii) Four copies of Phoiograph. iidenticaL to one Pasted on th€ applic?tior'r foim)

(xiii) Migratlon & or T.ansfer Certificale ftont the University/ Deemed University 1 lnstiluie lastAttended

("iu) Conduct Certificate iron the Universiry/ Deemed University / lnsUlule/school tastAttended

(xv) Proof oi Paymeni forAdmission F€e as per lnformaiion Brochure/ prog|ani

(>l,i) Aiildavil by the strrdent r egarding anii ragging

(xvii' Affidavii by the parenuguardian regarding anti-ragqiig

Undertakin! on stomp paler Jf Rs. 10001 regarding refund of scholarship in thp ffise oi:rl. Tech,JURP,Dual IJegreetiin.i

(xix) Medical Certificate should be issued from the registered Medical Practitioners/ Uovt. Doctors

2. Signature of documents Verifying Office(s):

1......................... 2...

fto be obtained at the time o, admission in presence of lnstitute representative only)

3. Full Signaturc of the Candidate: (English)

Left Thumb impression of the Candidate

Signature of Admission.ln.Charge of the DepartmenUlnstitute

Page - 3 of3

l) ,iii

To

The Notary Public

I

s/o

Resident of

P.S. District

do hereby solemnly declare and affirm as follows:-

1. That I have passed the qualifying examination

from in the year

2. That after passing the aforesaid examination I have not taken admission in

any college/ school/ institution during the period from

till this date.

3. That after passing of the qualifying examination, lwas not involved in anY

till this date.criminal offence during the period from

4. That from

-

the date of reporting/ admission to

the date of reporting for attending classes, I was sick

and was under treatment of Dr.

That the contents of this affidavit are true and correct to the best of my

knowledge and belief.l

Signature of the candidate/ Deponent

I ldentify the deponent who signed in my presence'

P.O

I Delcte/ Strike out if not applicable

Affidavi

r, Mr-/Mrs./Ms. AFFIDAVIT BY PARENT/GUARDIAN

- (,,,]. ,:"'" o'

. paren,suardian) fatner/ motfrer/ guardian of , --------------., --- -

(tullname or

6tudent vrlh admission/ resistration/ enrolmenl n,.I"O hiving been admitted to National lnstitute of

i""t,norogy patna (name of the institution) , have received _a

copy of the UGC Reg.ulations. on

;;;:;;srt; i;;"lci of Rasging in Higher'Educationat lnstitutions,2009, (hereinafter calred the;n"grlrii""r), Lr"tutty ruri-"nifrlly u-nd_erstood the provisions contained in the said Regulations'

2) I have, in pafticular, perused clause 3 of the Regulations and am aware as to what constitutes

ragging.'

3) I have also, in particular, perused clause 7 and clause 91 of the Regulations and am fully-' "rrr"

of the pehal and.administrative action that is liable to be taken agalnst my ward in case

ne/sne is found guilty of or abetting ragging' actively or passively, or belng part of a conspiracy'

to promote ragging.

4) I hereby solemnly aver and undertake that

a)MywardwillnotindulgeinanybehaviouroractthatmaybeconstitutedaSraggingunder clause 3 of the Regulations.

b) My ward will not partlcipate in or abet or propagate through alry act of commission or' ,rmission that may be constituted as ragging urider clause 3 cfthe Regulations'

5)lherebyaffirmthat,iffoundguittyofragging,myward.isliabteforpunishmentaccordingtoclause 6.t of tn" Regulations,-without preluOtce to any other criminal action thai nray be taken

against my ward undlr any penal law or any law for the time being in force'

b) I hereby dccla;e that my warC has not been expelled or debarred from admisl;ion in any

institutioninthecountryonaccountofbeingfoundguiltyof'abettingorbeingpartofaconsp;racytopron]ote'ragging;andfultheraffirmthat,incasethedeclarationisfoundtobeuntrue, thl admission of my ward is liable to be cancelled'

Declaied this

-

day of month of year.

Signature of deponent

llame:

'l-elephone/ tvlobile No. ;

VERIFICATION

Verified that the contents of this affidavit are true to the best of my knowledge and no part of the

affic.lavit is {alse and nothlng has been concealed or mlsstated therein'

Verified at

-

(place) on this the

- (dav) of

--- (month) ,

-

(vear )

solenrnly affirmed and signed in my presence on tnl the

- taa, o,

tillature of deponent

(year ) after reading the contents of this affidavit

OATH COIVMISSIONER

2o12

t,-AFFIDA.VIT BY THE STUDENT

{fuli name of sludent with

admission/ registralion/ enrolment number) S/O d/o Mr./MfS./Ms.

-

,'having been admitted to National lnstitute of Technology Patna {name or the

.nstitution) , have received a copy of the UGC Regulations on Curbing the Menace of Ragging in. Higher Educational lnstitutions, 2009, (hereinafter called the "Regulations") carefully read and

. fully understood the provisions contained in the said Regulations.

2\ I have, in particular. perused clause 3 of the Regulations and am aware as to whdtconstitutes ragging.

3) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fullyaware of the penal and administrative action that is liable to be taken against me in case I

am found guilty of or abetting ragging, actively or passively, or beinE part of a conspiracy topromote ragging

4) I heroby solemnly aver and undertake ihat

a) lwill not indulge in any behavior or acl that may be constituted as ragging underclause 3 of the Reguldtions.

b) I will not participaie in or abet or propagate through'any act of cornmissicn or'omission that may be constituted as ragging under clause 3 of the Regulations.

5) I hereby affirm that, if found gullty of ragging, I am liable for punishment according to clause9..1 of the Regulations, without prejudice to any other criminal actiorl that may be taken

against me under any pena! law or any law for the time being in force.

6) i hereby declare that I have not been expelled or debarred from idmisslon in any institutionin ihe country on account of being found giilty of, abetting or being pari of a€onspiracy topromote, ragging; and fut'ther afllrm that, in case the declaration is found to be untrue, I arn

aw.lie that my admission is liabie to be cancelled.

Declared this _day of month of _year.

Signature of deponent

VERIFICA'I'ION

Verifled that lhe contents of this affidavit are true to the besi of my knowledge and no part of theaffidavit is false and nothing has been concealed or misstated therein.

(place) on thls the

-

(day) of- (month) , -- (vear ) .Verifled ai

Signature of deponent

Solerrnly afnrmed and signed in my presence on this the (day) of (month), (year) after reading the

contents of this affldavit.

OATH COMMISSIONER

1, a12

Name:

,, .. . NATIONAL INSTITUTE OF TECHNOLOGY PATNA

' : '1 : '' ..' (An Institute under Ministry of HRD, Govt. of lndia)'1,:. ' ^:, ASHOK RAJ?ATH, PATNA-8OO OO5 (BIHAR)

MEDICAL EXAMINATION FOR PIIYSICAL FITNESS(

I. General Examination:

II. C.V.S. : Pulse: ..... . .. - ... .../ Minute;

]II.

Musculoskeletal System : Normal / Disabled (If disabled refer to a specialist)

VI.

uI.

VII,

IX.

Skin: ............... . . . . . . . . t

. . . . . . . . . . . . -

refective: ........... Spectacles. . . . . . . . . .Examination of Eyes: Normal / Defective: ........................... S

(If any abnoimality is found, refer to the specialist)

E.N.T,: Normal / Abnormal:(If any abnormality is found, refer to the specialist)

C.N.S.: ... :.................... :.........

Xj. Female Candidate: Menstrual History:

XIL Blood Group & Rh: ..........,......

I do hereby certify that I have examined tlie above candidate for admission to . .. .... Pt ogramme

in Nadonal Institute of Technology Patna, .... . . . department and cannot discover that he / she

has any disease and gonstitutional defect or bodily infrmity except that

...:......-... .,. ............... I rlo rrot consider tlis as a disqrralification lbr undcrguints tle abovc

progranune. His / Her age according to his/her own statement is . . .. .. years and by appearance

................ years.

Personal Marks of ldentificaiion:

1....................

2.,...................

Date:

Place: Signature of Doctor(With seal & Regd.No.)

(* Any defect to be noted in Detal

Weight.............Kgs.

UNDERTAKING

(On non-judical stamp paper of Rs. 1001)

I ........ ..........son/daughter of ....resident of...... hereby declare that I will refund theamount received by me from the institute as scholarship/stipend, incase of I withdraw from/leave the institute before completing therequisite criteria for award of my Ph.D degree as per the academic

regulation of the institute.

Signature of the candidate Signature of the Parent/Guardian