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Estd. 1997 SKIET SKIET f r kZ o H ¼ f l f d e t Z k Shri Krishan Institute of Engineering & Technology And Shri Krishan Polytechnic Estd. 2005 SKP SKP f r kZ o H ¼ f l f d e t Z k Sirsla Road, Ratan Dera, P.O. Pipli, Kurukshetra 136 131 (Haryana) Approved by AICTE, DTE & Affiliatecd to Kurukshetra University Registration/Admission Form (USE CAPITAL LETTERS ONLY) Name: Permanent / Correspondence Address: ....................................................................................................................... City: ........................................................ State:.......................................................... Pin Code .................................... Contact No.(With STD Code):...........................................................Mob: .................................................................. Email ID:............................................................................................................................................................................. Affix Your Recent Passport Size Coloured Photograph Course for which seeking admission (M.Tech - CSE, B.Tech - CSE, IT, ME, CIVIL, ECE), (Management - MBA & BBA), (Diploma- CSE, ME, CIVIL, ECE, EE, AE):- Category (SC/ ST/ OBC / GEN.) : 9. 7. 10. AIEEE/MAT CAT/ GATE / DET / LEET / DET-L (Tick as aplicable) Ö Rank Roll No. Sr. No. _____________ Course ................................................................. Direct/ LEET/DET-L .............................. Branch ........................... 8. Domicile State: 11. (a) Academic Record : Sr. Exam Max. Marks Marks Obtd. University/Board Yr. of Passing Roll No. %age 1 2 3 4 10th 10+2 (PCM Only) Graduation .......................... Others .................................. (b) Gap Years: ................................................................................................... (c) Have you ever been disqualified from studies : YES/NO 1. th Father's Name: ............................................................................................................................. (As given in 10 Certificate) 5. Date of Birth: 3. Sex (Tick Ö): Male Female 4. Nationality:........................ 2. 6. Parent's & Guardian Details Father Mother Occupation Contact Nos. & Email ID 12. Parents Information: th (As given in 10 Certificate)

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Page 1: Shri Krishan Institute of Engineering & Technology And ... · Shri Krishan Institute of Engineering & Technology And Shri Krishan Polytechnic Estd. 2005 SKP ¼HkZofr lff t Sirsla

Estd. 1997

SKIETSKIET

frkZoH¼flfdetZ k

Shri Krishan Institute of Engineering & TechnologyAnd

Shri Krishan Polytechnic

Estd. 2005

SKPSKP

frkZoH¼flfdetZ k

Sirsla Road, Ratan Dera, P.O. Pipli, Kurukshetra 136 131 (Haryana) Approved by AICTE, DTE & Affiliatecd to Kurukshetra University

Registration/Admission Form(USE CAPITAL LETTERS ONLY)

Name:

Permanent / Correspondence Address: .......................................................................................................................

City: ........................................................ State:.......................................................... Pin Code ....................................

Contact No.(With STD Code):...........................................................Mob: ..................................................................

Email ID:.............................................................................................................................................................................

Affix YourRecent

Passport SizeColoured

Photograph

Course for which seeking admission (M.Tech - CSE, B.Tech - CSE, IT, ME, CIVIL, ECE), (Management -

MBA & BBA), (Diploma- CSE, ME, CIVIL, ECE, EE, AE):-

Category (SC/ ST/ OBC / GEN.) :

9.

7.

10. AIEEE/MAT CAT/ GATE / DET / LEET / DET-L (Tick as aplicable)Ö

Rank Roll No.

Sr. No. _____________

Course ................................................................. Direct/ LEET/DET-L .............................. Branch ...........................

8. Domicile State:

11. (a) Academic Record :

Sr. Exam Max. Marks

MarksObtd.

University/BoardYr. of

Passing Roll No. %age

1

2

3

4

10th

10+2 (PCM Only)

Graduation ..........................

Others ..................................

(b) Gap Years: ...................................................................................................

(c) Have you ever been disqualified from studies : YES/NO

1.

thFather's Name: ............................................................................................................................. (As given in 10 Certificate)5.

Date of Birth: 3. Sex (Tick Ö): Male Female 4. Nationality:........................2.

6.

Parent's & Guardian Details

Father

Mother

Occupation Contact Nos. & Email ID

12. Parents Information:

th(As given in 10 Certificate)

Page 2: Shri Krishan Institute of Engineering & Technology And ... · Shri Krishan Institute of Engineering & Technology And Shri Krishan Polytechnic Estd. 2005 SKP ¼HkZofr lff t Sirsla

Place: .....................................

Date: .........../........../...............

...........................................Guardian's Signature(with relation & full Name)

...........................................

Student's Signature

FOR OFFICE USE ONLY

Details of Fee Deposited (Amount) Category : SC/ST/OBC/Gen.

by Draft / Cheque / Cash Receipt No. .................................. Bank .............................................. Date .........................

Registration No. ......................................... Roll No. .................................. Admitted to Course ...................................

Branch ........................................ Reference: .........................................................................................................................

CHECKED BY VERIFIED BY:

Signature .............................................

Name .................................................... ...................................................

Director/Chairman

Signature .............................................

Name ....................................................

Remarks........................................................................................................................................................................................................

DECLARATION

I) I_______________________________________________________ hereby certify & confirm that the information filled in the

Applications Form is complete and accurate in all respect, I understand and agree that misrepresentation of facts will justify

denial of admission/ cancellation of admission/ expulsion from the institute.

ii) If at any stage, it is found that I do not fulfill the minimum prescribed eligibility criteria of the University/Haryana Technical

Board, admission granted to me by the Institute can be cancelled and I will have no right/claim towards the Institution.

iii) I declare that information furnished by me in the application form is true in all respects and in case any entry or information is

found to be false, this shall result in automatic cancellation of my admission besides rendering me liable to such action as the

university may deem fit. I hereby undertake that I have carefully gone through the eligibility conditions prescribed in the

prospectus/website for the programme. I am applying for and shall appear in the entrance examination/direct counseling of

the Institute after satisfying myself that I do fulfill the same.

15. Applying for Hostel : YES/NO

(a) 10th ..........................................................

(c) ITI ............................................................

(e) SC/ST.......................................................

13. Detail of Guardian:

Name: ........................................................................................................... Relationship: ............................................

Address: .............................................................................................................................................................................

Contact Details: ...........................................................................Email ID:....................................................................

Guardian Annual Income:

Name: ........................................................................................................... Relationship: ............................................

Address: .............................................................................................................................................................................

Contact Details: ...........................................................................Email ID:...................................................................

14. In case of any emergency, who should be contacted:

(b) 10+2 ..........................................................

(d) Graduation .............................................

(f) Domicile ..................................................

16. Documents Attached (Equivalent to):