APPLICATION FORM

FOR ADMISSION TO
B. TECH (BIOTECHNOLOGY / BIOINFORMATICS AND DATA SCIENCE / FOOD
SCIENCE AND TECHNOLOGY)
(ACADEMIC YEAR 2018 – 19)

D. Y. PATIL DEEMED TO BE UNIVERSITY, NAVI MUMBAI

(Established under Section 3 of the UGC Act, 1956 vide notification no. Application Number
F.9.21/2000-U.3 dated 20.06.2002 of the Govt. of India)
NAAC Reaccreditation: “A” Grade
Plot – 50, Sector – 15, CBD Belapur, Navi Mumbai – 400 614. Paste photograph here
(Taken not more than 3
months prior)
photograph here

Important Instructions:
Please read instructions given in the Prospectus for filling the form

1. Name of the student:

[NAME IN CAPITAL]

________________________________________________________________________
(SURNAME) (NAME) (FATHER’S NAME) (MOTHER’S NAME)
Paste photograph here
2. Category: a) General Reserved (Taken not more than 3
months prior)
b) SC ST OBC NT DT photograph here

Others, Please Specify ……………………………………..

3. Nationality: ____________________

4. Religion: _______________________

5. Date of Birth: _____ / ______ / ______________ (DD/MM/YY)

6. Sex: Male Female

7. Place of Birth: _____________________________

8. Address of Correspondence: _______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

9. State: ________________________________________________

10. Pin Code: _______________________________

11. Parent / Guardian’s Email Id: 1) _______________________________________________________

Student’s Email Id: 2) _______________________________________________________________

12. Telephone No. Residence: _____________________ Mobile No. _________________________

(with STD Code)
13. Telephone No. Office: ______________________ Mobile No. ___________________________
(with STD Code)

14. Fax No. (With STD Code) ________________________________

15. Permanent Address: _______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

16. Name of the Board of Qualifying Examination : _______________________________________

17. Name of the Qualifying Examination: _______________________________________________

18. Whether Qualifying Examination Passed / Appeared : Passed Appeared

19. Percentage of marks in the Qualifying Examination:

20. Marks obtained in the

Maximum Minimum for
Subject Mark Obtained
Marks Passing
Physics
Chemistry
Biology (or)
Botany
Zoology
Mathematics
Total PCB / PCMB
English

21. Order of Preference of Programme:

1. B. Tech Biotechnology
2. B. Tech Bioinformatics and Data Science
3. B. Tech Food Science and Technology
(Please fill in order of preference from left to right in the boxes above with the number given for each
course. Admission to the programs will be strictly as per order of preferences mentioned by the candidate
in the application form.)

22. Whether for recognized national / state level entrance examination: Yes / No

23. IF yes, name of entrance examination ________________________________________________

24. Details of the Application Form Fees Paid

Mode of payment DD Cash

Name of the Bank: ______________________________________________________________
Issuing Bank: ____________________________ DD No. _______________________________
Date: _________________________ Amount: _______________________________________

____________________
Candidate’s Signature