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School of Biotech Sciences Trident technoplex,Plot No. F2/B,Chandaka Industrial Estate Infocity Area, Bhubaneswar – 751024, Phone/Fax : (0674) 6649025, 6538419 APPLICATION FORM 2012 (Affix your colour photo signing it 01. Name (Block Capitals) : across the 02. Father’s / Guardian’s Name : border on form and 03. Date of Birth : photo) 04. Sex (Please √ ) : M F 04. Educational Details : Course Institution Board / University Year of Aggregate % Subject Passing of Marks 10th +2 +3 (Please attach attested Xerox copies of marksheets and pass certificates for each of the above exams along with a copy of conduct certificate from the institution last attended. Copies of final year marksheet and certificate for (+3)an be submitted separately by 28.08.2012 if results are awaited. Till then Admission will be provisional) 05. (a) Address for Correspondence : (b) Permanent Address : 06. (a) Tel. No. with STD Code : (c) E-Mail : (Mention if PP No.) (d) Mobile Self : (b) Fax : Guardian : 07. Course applied for (Please √ ) : (1) M. Sc (Biotechnology) (2) B. Sc. (Biotechnology) 08. Whether Hostel Accommodation is Required (Please √ ) : Yes No. 09. Whether Transport Facility Required (Please √ ) : Yes No. If Yes, Specify Pickup Point ______________. 10. DD/Cash Receipt No. and Date Towards application fee( Rs. 200/-) : Place : Date : Full Signature of the applicant * All payorders/banker’s Cheques/demand drafts should be drawn in favour of “TACT” payable at Bhubaneswar . Scholarship is available according to merit.
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