· Web viewTuition fee Other fee, if any Transport Hostel accommodation fee Food 1 st year 2 nd...
Transcript of · Web viewTuition fee Other fee, if any Transport Hostel accommodation fee Food 1 st year 2 nd...
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Paste (DO NOT STAPLE) a recent
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DRIEMS (AUTONOMOUS)TANGI, CUTTACK.
ADMISSION FORM (Details to be filled by the candidate in Block Letters)
1. Name of the Student:…………………………………………………………...
2. Applied for admission to B.Tech / M.Tech, Branch ………………………
3. Gender: Male/Female 4. Date of Birth: ……………………
5. Nationality:…………………6. Religion:……………………........
7. Mother Tongue:……………… 8.Contact No. 1: ……………..... , ContactNo.2:…………………..9. Reservation: (Put tick √ mark)
10. Email ID: …………………………………………………………………11. Whether wish to stay in the college Hostel: (Put tick √ mark)
12. Details of Entrance Examination
Name of Entrance: ……………………….. Rank/ Score:…………………………….
13. Details of Academic CareerSl. No. Name of the
ExaminationSchool/College Board/
UniversityYear of Passing
%of Marks Medium of Study
1. 10th
2. +2/Diploma
3.
11. Languages and skills known place tick √ mark.Language Known Read Write Speak
12. Details of Parent/Legal Guardian:Sl.No. Contetnt Father/ Legal Guardian Mother/ Legal Guardian Local Guardian
1. Name
2. Occupation
3. Annual Income
4. Mobile No.(IMP)
5. Email Id:(IMP)
13. Address for Correspondence:PRESENT ADDRESS PERMANENT ADDRESS
Contact No. PIN: Contact No. PIN:
General SC ST OBC PH
YES NO
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14. List of Documents Enclosed (Please Write YES or NO)1. HSC/10th Certificate 6. Migration Certificate2. HSC/10th Mark Sheet 8. 9. 7. Caste Certificate (SC/ST/OBC)3. +2 /Diploma Certificate 8. Resident/ Nativity Certificate4. +2 /Diploma Mark sheet 9.Income Certificate5. CLC &TC 10. Adhaar Card (mandatory)
11.10 self address stamped envelope
DECLARATION BY THE CANDIDIATEI hereby undertake that:
1. I shall be regular, punctual and sincere in attending all the classes. If my attendance falls short of 75% in any subject (65% in Medical ground with a valid medical certificate), fine will be imposed on failure in fulfillment of requisite no. of attendance in theory & laboratory, if it falls below the purview of compensation with the extra classes.
2. Otherwise I will be debarred from appearing the University Examinations/Internal Examinations in that subject as per university Regulation.
3. I will be penalized if I remain absent from the college on last working day before vacation and on the opening day after vacation.
4. I will be penalized as per the decision of the Academic Committee / BPUT Guide lines, if I found to be involved in MASS BUNK and if I fail to submit the sessional records on time and unable to appear the Internal Examination on time.
5. I will show due regards to all the teachers and staff of the Institute and senior students. 6. I shall not be involved in ragging in any form. Moreover I will report to the concerned authority
immediately if I come across any case of harassment or ragging caused to others by any student.7. I will develop a friendly relationship with the fellow students. 8. I will maintain the decorum of the Institute (Dress, Appearance, Discipline and Attitude) in the class
room, in the Examination halls, Hostel and inside the campus. .9. I will not adopt any unfair means during the time of Examinations. (Both in internal & University).10. I will not damage or steal any property of the college, hostels, fellow students and staff. 11. I will not involve in smoking, chewing of tobacco, consumption or distribution of alcoholic drinks or any
kind of Hallucinogenic drugs inside or outside the college and hostel premises. 12. I will not organize, instigate or participate in any illegal group activity except purely academic programs
either inside or outside the campus without prior valid permission of the Dean/HOD/ Principal/Director.13. The authority will not be held responsible for any unexpected incident (involving self) outside the
campus in case of unauthorized absence from the college.14. I will not have any unauthorized possession of library books.15. I will not have any unauthorized possession of weapons in any form.16. I will intimate about my absence/temporary absence to the Proctor/HOD/ Warden /superintendent of the
Hostel. Failing which college authority will not be held responsible for my own negligence/absence. 17. I will pay my college fees & hostel dues (if any) on time. College dues fixed as year Tuition fee Other fee, if any Transport Hostel accommodation feeFood
1st year
2nd year
3rd year
4th year
N.B-i. financial transaction should be through DD/RTGS/NEFT only with a valid proof of account section. ii. Cash payment in any form is strictly prohibited. Cash in any form is the sole responsibility of either Candidate or parents or legal guardians.
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iii. I know apart from the above some optional fees will be charged extra to add some value added /career advancement & PPT courses, which will be helpful towards support of my placement drive. I will definitely join the programme organized by Institution directly or indirectly, which will be helpful for my career growth. Failing which I don’t have claim on institution regarding my placement assistance.iv. I know college is providing …………..% incentive, if I will clear my full dues before 15 th July of each session.v. I know in case of default in payment of dues, bank interest will be charged @personal bank loan interest. vi. For further default in payment action will be taken by the Committee / Authority / Management as deemed fit.vii. I know-------------------- Scholarship will be awarded to the meritorious students i.e. per year / for 1st
year.viii. In my case it has been finalized at Rs ------------------- (Rupees …………………………………………………) only / per year / for 1st year, as per my 10th & +2 mark or qualifying exam conducted by the institution.(mark TICK whichever is applicable)
18. University semester registration fee will be charged extra. 19. I will not create ill feelings amongst students based on State, Locality, Caste, Sex and seniority-
Juniority. 20. The institution is not responsible for any kind of life threatening attempt (suicide) by the student.21. Ignorance of rules & regulations would not be treated as matter of excuse.22. Any dispute regarding law can be settled in the jurisdiction of Cuttack District only.
I do undertake that if I will not obey the above rules and regulations of the college, I may be liable to punishment such as debarment from the student activities and receiving medals / prizes / scholarships / certificates, campus placement, forfeit of the caution money, expulsion from the hostel and college either temporarily or permanently, debarment from the internal / sessional examination, imposition of fine without any information to the Parents / Legal / Local Guardian, according to the severity of the offence. I or my Parents / Legal Guardian will not go to court of law due to our own fault /negligence.
Counter Signature of the Parents / Legal Guardian Full Signature of the Student with date
Signature of the Promotional Staff (if any) : ___________________________ Date:-
FOR OFFICE USE ONLYAdmission No.: Course: Branch: Regular/ Lateral Entry: Year of Admission: Roll No. : JEE RANK No. REGD. NO: Date of Verification:
Signature of the Admission-In charge Signature of the Principal/Director (Admin)