Application form for VITEEE - 2013

Full Name
Date of Birth Religion Community Native State Landline No. Parent name Choice of Campus Qualifying Exam Exam Roll.No./Reg.No. Permanent Address Name of the School Address of the School DECLARATION I solemnly and sincerely affirm that I am an Indian National and that all particulars furnished by me in this application form are true and correct . I have not concealed any information. However, in the event of any information being found to be incorrect, fraudulent or untrue, either before or after the examination or after my admission to the programme, I understand that I am liable to face criminal prosecution and the management can claim all authority to cancel my candidature / selection or admission as the case may be and I would have to forego my seat and the fees. I agree to abide by the rules and regulations governing the examination as well as the rules pertaining to the refund of tuition and hostel fees contained in the brochure. I further undertake to submit all the required certificates as per the rule, either at the time of interview or during the admission process, failing which I understand that I would have to forego my seat and the fees. Date : Place : Signature of Parent / Guardian Signature of the Applicant

: AKASH TIWARI
: 05/03/1996 : Hinduism : General/OC : Bihar : : GYANENDRA TIWARI : Vellore : 12th Class :

Application. No. : 2013081625

Gender Nationality Mother Tongue Mode of Study Mobile No. Hostel Email ID. Month & Year Passing Testcity : MALE : Indian : Hindi : Regular : 9868384943 : Yes : akashtiwarix95@gmail.com : Mar - 2013 : DELHI

: RZ - 243 P-F-87, PALAM COLONY,DELHI CANTT,West,Delhi,110045. : Modern international school : Sector-19 dwarka, new delhi, West,Delhi, 110077.

PASTE FIRMLY YOUR RECENT COLOUR PHOTOGRAPH OF GOOD QUALITY (SIZE 3.5 X 4.5 CM)

PLEASE WRITE YOUR NAME AND APPLICATION NO. ON THE BACK SIDE OF THE PHOTOGRAPH BEFORE AFFIXING.

Payment Acknowledgement Copy VIT ONLINE APPLICATION SALE Payment Option Made:-NetBanking / Credit Card / Debit Card. Bank Reference No.:201301036571667 Applicant Name:AKASH TIWARI Contact No.:9868384943 Transaction No.:60794477 Application No.:2013081625

Transaction Date:03-01-2013 01:51:09

Application Fee : Total Amount:

900.00

Service Charge(including service tax):

34.00

934.00 (Rupees Nine Hundred And Thirty Four Only).

Note : 1.It is mandatory that the candidate should send the hardcopy of the application form to the address of the Director - UG Admissions,VIT University, Vellore -632014,Tamil Nadu. 2.Candidate should retain the photocopy of the application form.

VITEEE - 2013 Application. No. : 2013081625 Applicant Name : AKASH TIWARI

BY REGISTERED POST / SPEED POST ONLY

To
Mode of Payment
Demand Draft ( DD ) Net Banking / Credit card / Debit card

: :

THE DIRECTOR - UG ADMISSIONS, VIT University, Vellore - 632014, Tamil Nadu, INDIA.

-------------------------------------------------------------------------------------------------------------------------------------------------------- The Above address may be pasted on the envelope.

Student Copy

PLEASE INSERT THE APPLICATION FORM IN THE ENVELOPE IN SUCH A MANNER THAT THE BARCODE ON THE APPLICATION FORM IS NOT FOLDED.

CHECKLIST FOR THE CANDIDATE

1.Tick the box if you have enclosed the following documents: a. Completed Application Form with your signature. b. Completed Application Form with your parent's / Guardian's signature. c. Your color photograph (of size 3.5 cm x 4.5 cm) affixed on application appropriately. d. Have you entered your correct Date of Birth. 2.Retain a photocopy of the completed application form with you. 3.Send your application form to the VIT as mentioned on the address slip