FACULTY OF ENGINEERING & TECHNOLOGY / PHARMACY / MANAGEMENT x) PRIST serio iE Siuwesry 2013 bonciiests Application NO + Flldeisin Elis sing CAPITAL Later: + Used oe ls Hah pint on ling des + Phe ik weve aed + Ml file apiaton Te oT edits Pa sy GL Systems Certification 20-20 Vila, Tanja Na ai CAMPUS, Programme Appl Regie =O CotHansavur Orrichy Ol puoucherry Oi chennat Ci kumpakonam CImapural 0 5 ‘SPECIALIZATION Owurecr. Omsa Ompnarm. 1, PHOTOGRAPH APPLICANT'S INFORMATION tren Name Past your recent passport, Siz eae ghotopaph Dos Age Gender en Religion GHindu CO mustim christian others Community : General)oc osc Osc Omec O onc scO st otners Specity: Nationality : OJ indian C1 nri O) Foreign National (Citizenship) Hostel Required Mother Tongue Bod rou Oves Ono SCIENCE cr Father's Name Mother's Name Father's Mobile onesie Father's | Annual Pa Occupation ome z Mothers | Ato - Cccupation ome z ADDRESS FOR CORRESPONDENCE (DO NOT REPEAT NAME) Fs Bs Pin Code Distct FE Stale County F Telephone a Mobil B nd with Code 3 E-Mail Es PERMANENT ADDRESS (DO NOT REPEAT IF IT IS SAME AS ABOVE) Pin Code District State Country oo Telephone with Coderos merehy Dax SCIENCE PONNATYAH RAMAJ EDUCATIONAL QUALIFICATION mesmottamet | | | | | | |i titi tittititti tt MARKS DETAILS (Under Graduate) - COURSE. UNIVERSITY: INSTITUTION: TseM SEM TSeM sem Vsen Visew Visew WuiseM ‘SECURED/MAX. MARKS | OVERALL% | YEAROF PASSING | ACADEMIC YEAR MODE OF STUDY Regular CI Part Time OI Correspondence MARKS DETAILS (Post Graduate) - COURSE. UNIVERSITY: INSTITUTION: TseM SEM TSeM Ivsem Vem Visew ViSEW WuiseM ‘SECURED/MAX. MARKS | OVERALL% | YEAROF PASSING | ACADEMIC YEAR MODE OF STUDY Ceguar CI Part Time OI Corespondence CERTIFICATE DETAILS ‘OFFICE USE ONLY i Cortiicates Certificate No. | N&O, | § Contifeates Certiticate No. | ogNti ots 1_[ Transfer Certieate 10 _| Fest Graduate Ceriicate 2__| 0th Mark Sheet 11_| Allotment Order 2. [2th Mark sheet 12_| Fitness Certfcate 4 | Consolidated Mark Sheet 13_| Bank Receipt Chalian| 5 | Provasional Certiiate 14 [ TNCET- Mark Sheet 6 | Degree / Diploma Certfcate 15 [ TNCET- Hall Ticket 7 _| Migration Certificate 16_| Mark Sheet Nos 8_| Residence Certfoate ® | Community Certificate “Total No.of Cenificates + Must enciose 2 sets of attested photocopies of al originals in A4 size paper. DECLARATION | hereby declare thatthe entties made in the application form are correct to the best of my knowledge and belie. Note thatthe decision of the University is nal with regard tothe selection for acmissio. If selected for Admission, | promise to abide by the rules and regulations ofthe University land the guidelines inthe prospectus. The University shal have the right to expel me from the University al any time after admission Provided ii saisied that | was admitted on false partculars furnished by me or my antecedents prove that my continuance in the University isnot desirable. | ‘gree that all disputes are subject to the jurisdiction of the courts of Chennai only. Fees paid on counseling and admission will not be claimed back Under any ercumstances, ‘SIGNATURE OF PARENT / GUARDIAN SIGNATURE OF APPLICANT. DATE PAYMENT DETAILS Enclose Tultion fee in the form of @ crossed demand drat in favour of “PRIST University” payable at Thanjavur / Trichy / Puducherry ! Chennai / Kumbakonam / Madurai, along with your completed application form, Name of the Bank Demana Orato] || | | || {|| om Eft pp ppd} amour fe | || | | DATE: SIGNATURE OF THE ADMISSION STAFFANNEXURE | AFFIDAVIT BY THE STUDENT 1 (full name of student with admission/registration/enrolment number) Slo - Dio MriMrs./Ms, 1) Having been admitted to Ponnaiyah Ramajayam Institute of Science & Technology (PRIST University) have received a copy of the AICTE regulations on Curbing the menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the "Regulations") carefully read and fully understood the provisions contained in the said Regulations. 2) Ihave, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging, 3) Ihave also, in particular, perused clause 7 and clause 9.1 of the Regulation and am fully aware of the penal and administrative action that is liable to be taken against me in case | am found guilty of or abetting ragging, actively or passively, or being part of a conspiracy to promote raging. 4) Thereby solemnly aver and undertake that a) | will not indulge in any behavior or act that may be constituted as raging under clause 3 of the Regulations. b) | will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging under clause 3 of the Regulations, 5) Ihereby affirm that, if found guilty of raging, | am liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against me under any penal law or any law for the time being in force. 6) Thereby declare that | have not been expelled or debarred from admission in any institution in the country on account of being found guilty of, abetting or being part of a conspiracy to promote, raging; and further affirm that, in case the declaration is found to be untrue, | am aware that my admission is liable to be cancelled. Declared this (day) of, (month) of, (year) Signature of Deponent Name: VERIFICATION Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit is false and nothing has been concealed or misstated therein. Verified at (place) on this the (day) of _______(month)_(yeary Signature of deponent Solemnly affirmed and signed in my presence on this the (day) of (month) (year) after reading the contents ofthis affidavit. OATH COMMISSIONER ACKNOWLEDGMENT (tor office use only) Received your Application No, for Admission to the Course With Registration/Admission No Date & Seal Signature of Admission Staff iteeren SCIENCE AND cr Pa PennineAND TECHNOLOGY SCIENCE fs ORE UR EN ANNEXURE II AFFIDAVIT BY PARENT/GUARDIAN 1 Mr./Mrs/Ms. (full name of parentiguardian) Father / Mother / Guardian of (full name of student with admission /registration/enrolment number), 41) having been admitted to Ponnaiyah Ramajayam Institute of Science & Technology (PRIST University) have received a copy of the AICTE regulations on Curbing the menace of Ragging in Higher Educational institutions, 2009, (hereinafter called the "Regulations") carefully read and fully understood the provisions contained in the said Regulations 2) Ihave, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging 3) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against my ward in case he/she is found uilly or abetting ragging, actively ‘or passively, or being part of a conspiracy to promote raging 4) Thereby solemnly aver and undertake that a) My ward will not indulge in any behavior or act that may be constituted as ragging under clause 3 of the Regulations. b)_ My ward will not participate in or abet or propagate through any act of commission or omission that may be constituted {as ragging under clause 3 of the Regulations. 5) hereby affirm that, if found guilt of ragging, my wordis liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against my ward under any penal law or any law for the time being in force. 6) I hereby declare that my word has not been expelled or debarred from admission in any institution in the country on account of being found guilty of, abetting or being part of a conspiracy to promote, ragging; and further affirm that, in case the deciaration is found to be untrue, | am aware that my admission my word is liable to be cancelled Declared this (day) of. (month) of (year) Signature of Deponent Name: Address: Telephone/Mobile No: VERIFICATION Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit is false and nothing has been concealed or misstated therein. Verified at (place) on this the (day)of________(month)____year) Signature of deponent Solemnly affirmed and signed in my presence on this the _(day) of ___(month)_(year) after reading the contents of this affidavit. OATH COMMISSIONER