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APIIT_BE_Application_Form

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					                                             Application Form
     Affix a self
      attested                                                           Application No.
    photograph
                                                                        Semester No.___________ Roll No._____________
                                                                        (For office use)


Name (Block letters)____________________________________________________________________________________________
                                    (First name)              (Middle name)            (Last name)


Father’s Name/Guardian Name__________________________________________________________________________________
                                      (First name)              (Middle name)             (Last name)

Father’s Occupation _______________________________________Post/Designation_____________________________________

Office Address_________________________________________________________________________________________________


Mother’s Name/Guardian Name__________________________________________________________________________________
                                     (First name)              (Middle name)             (Last name)

Mother’s Occupation ______________________________________Post/Designation______________________________________

Office Address________________________________________________________________________________________________


Date of birth        DD                   MM                     YYYY


Gender              Male                Female


Educational Description
                                                                                  % in
 Class      Name of the Board                    Name of the School                          % in PCM     Remarks
                                                                                aggregate

 12th

 10th


Merit Description

  Sr.                                                                                                Ranking in
  No.                 Name of the Competitive Exam appeared (if any)             Roll No.
                                                                                                    Examination


   1.

   2.


Category (Please Tick)
         General                  OBC                    SC/ST          Physically Handicapped
Permanent Address                                                                 Correspondence Address




Pin :                                                                             Pin :

Tel. :                                                                            Tel. :

Email :                                                                           Mobile :
(Filling of Email and Mobile number is mandatory for students opting for online test)




Details of Payments

Cash / Draft No. __________________________________________ Dated__________________

of amount______________________________drawn on_____________payable at___________

I certify that above mentioned information is correct and complete in all respect.




Date:__________________
                                                Candidate Signature                          Parent / Guardian Signature


Checklist
           The following documents are required along with the application form:

            Duly filled application form.
            A Demand Draft of ` 500/- in favour of APIIT SD INDIA, payable at Panipat.
            In case of OBC/SC/ST, the photocopy of certificate of the respective category from the
            competent authority.



Semester Topper Reward

To promote a healthy competition among students, APIIT Provides Cash Reward & Certification to the
1st, 2nd and 3rd ranked students of each semester




          Approved by AICTE, MHRD, Govt. of India and Dept. of Technical Education, Govt. of Haryana

                                         APIIT SD India, Faridpur Road, G T Road, Karnal Side,
                                                    Panipat 132103, Haryana (INDIA)
                                 Tel:+91 0180-6532444, 0180-6532555 Tele Fax: +91 0180-2577273
                                          email: info@apiit.edu.in website: www.apiit.edu.in

				
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posted:12/24/2010
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