Raj Kumar Goel Institute of Technology, Ghaziabad

(Approved by AICTE, Govt.Of India, and Affiliated to Uttar Pradesh, Technical University, Lucknow.)

Registration Form-(ODD SEMESTER) '' SESSION-2017-18"

Name: ANURAG AZAD Date of Birth 08/15/1996

Name in Hindi Roll No : 1503300021

Branch CE Semester Sem V Section A1 Enrollment No

Year : 2015 Mobile No.(Student) 9958128122

Mobile No.(Father) 9760537066 Mobile No.(Mother) 9958128122

Mobile No.(Friend) 9456948803 E-mail ID.(Student) anurag.azad14@gmail.com

Father's Name Rishi Pal Singh Occupation Govt Employee

Mother's Name Nirmal Occupation Housewife

Annual Income Mother's nill
Annual Income Father's 600000
Mode of Admission
Caste SC
Blood Group B+ Aadhar No. 504217844795

Gender Female
Details of Previous Year Performance :
Examination Passed Board / Univ. Year of Passing Subject Name PCM % Over All %
CBSE 2012 maths,sst,science,english,hindi 90 86
X
XII(PCM) CBSE 2014 maths,physics,chemistry,english,physical 68 75

B. Tech/B. Pharma/MBA/MCA/M. Pharma Ist Year IInd Year III rd Year

Marks Obtained(%) 65 70 00

Hostelor or
hosteller No . of Carryover
Day Scholor
papper Subject Code

Complete Address :

Permanent near tail tankey railway colony bunglow no

Local B-17 ganeshpuri shahibabad(gaziabad
e-5-b Shahjahanpur
Pin Code 110095 State Uttar Pradesh
Pin Code 110095 State Uttar Pradesh
Tele no. with code
Tele no. with code
Local Guardian address
MobileNo of Local Guardian

E-mail Id(Father) E-mail Id(Mother)

Mode of fee Payment cheque/draft

DECLARATION BY STUDENT

I hereby declare that the entries in the registration form are true to the best of my knowledge and belief. I have
carefully read the instructions given in the student manual/ Undertaking/Affidavits and hereby undertake to abide by them. I
further declare that no criminal proceedings are under process or pending against me with the Police or in any Court of law.
I also undertake to fulfill the required criteria of attendance (75%) and in the case of short attendance, I will be liable to be
detained from the sessionals as well as the end semester examinations.
I will be liable for disciplinary action if found violating any rules/undertaking/orders/instructions etc.
Date.....12-Jul-2017........................................................
Place............................................................
(Name & Signature of Class Coordinator/Counselor)..........................(Student’s full signature)……………………

(............................................................) (...........................................................)
(Name of HOD) (Signature of HOD)
All Red Color Filed the mandatory. Filled the form very carefully. After filling the form save it & take the print out for further process.