RUSTAMJI INSTITUTE OF TECHNOLOGY
BSF Academy, Tekanpur, Gwalior – 475 005 (M.P.) Tel.:- (07524) 274319, Fax (07524) 274320 e mail: firstname.lastname@example.org ------------------------------------------------------------------------------------------------------APPLICATION FORM FOR ADMISSION IN B.E. -2013 (FOR BSF/CPO’s WARDS ONLY) RJIT Roll No. (For RJIT use only) 1. Name in Full (In Block Letters) (As per 12th Marksheet) Father’s Name (In Block Letters) Mother’s Name (In Block Letters)
JEE Main Roll No. (To be filled by candidate) Affix your recent passport size colour photograph attested by Unit/HQ Comdt. or his authorized Signatory
Contact No. (Telephone No.) (Mob No.)
5. 6. 7.
E-mail ID (a) Candidate ___________________ (b) Father ____________________ Identification Mark of Candidate ____________________________________________ Date of Birth D D M M Y Y Y Y (As per 10/12 Marksheet) Sex Tick √ Male Female
9. 10. 11. 12.
Organization (BSF/CPO’s) ____________ Unit____________ (only BSF employees) Rank (only BSF wards) : Wards of Officers/SO’s/OR’s/Widows Religion _____________Category Tick √ Gen SC ST OBC
If secured Gold Medal in National Level Games and Sports Meet Tick √ Yes No
If, yes then attach appropriate certificate issued by the competent authority. 13. 14. If physically handicapped Tick √ Yes No
If, yes then attach appropriate certificate issued by the competent authority Are you a Resident of J & K? Tick Yes No √ If, yes then attach appropriate certificate issued by the competent authority. Are you a Kashmiri Migrant? Tick Yes No √
If, yes then attach appropriate certificate issued by the competent authority. 16. Academic Qualifications Examination School/College Board Subject Year of Passed Passing (Class 10th Onwards)
Percentage of Marks
Last academic qualification obtained (with year)
Branch preference (To be filled in order of choice) (a) Electronic & Communication Engg (ii) Automobile Engg. (iv) Mechanical Engg. (v) Electrical Engg. (a) ____________________ (ii) (v)
(iii) Information Technology
_______________ (iii) _______________
(iv) ___________________ 18. Details of Bank Draft Branch Draft Number
Amount * 400/- / 200/*Note : Enclosed a Draft of Rs. 400/- (Rs. 200/- in the case of Widows Wards ) in favour of Principal, RJIT, payable at SBI, Tekanpur (Code No. 8284) only be enclosed. 19. Postal Address for Correspondence
O N E Permanent Address
O N E N O. Address where parents serving
22. Whether your real Brother/Sister is already studying in/passed out from RJIT. (Yes/ No) If yes give details :(Name ___________________________ S/o _______________________ BE (Automobile Engg./ Electronics/ Information Technology/ Mechanical Engg/Electrical Engg)(Sem ____Year of passing _____) Certificate from Head of the Institute/College/School (for candidates who have appeared for the qualifying examination and the result is awaited) This is to certify that Mr/Ms _____________________________________ is/ was a student of this institute in the academic year ______________________ and has appeared for ___________________ Examination under ______________________Board/University as a regular/private candidate. Signature ____________ Seal of the Institute Designation ____________ 23. Declaration by the applicant & parents I hereby declare that all the particulars given in the application and the enclosures are true to the best of my knowledge and belief. If any of the particulars are found incorrect, my candidature may be cancelled. I hereby undertake to be present with all the requisite original documents at the time of counselling. Signature of the applicant I hereby certify that the information in the application form is correct and the photographs affixed on the...
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