Application Form by X8ee493

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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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