Appl. No.

Seethakathi Estate, G.S.T. Road, Vandalur, Chennai - 600 048. India.

Space for affixing
Passport size
Photograph

APPLICATION FOR ADMISSION TO

M.Tech. DEGREE 20 - 20
DEPARTMENT

: CIVIL / MECH / EEE / ECE / EIE / CSE / IT /

POLYMER / PHYSICS / MCA

PROGRAMME

PROCEDURE AND INSTRUCTION FOR FILLING THE FORM :

1. Read all the instructions carefully before filling in the application form.
2. Mark in the appropriate box wherever applicable.
3. The candidates should attach attested photocopies furnishing the details of marks age, community and Gate
score (if applicable).
4. Incomplete application will be rejected.

1. NAME (IN BLOCK LETTERS)

ADDRESS FOR COMMUNICATION

_________________________________________________________
_________________________________________________________
_________________________________________________________
________________________ Pincode

TELEPHONE NO. :

________________________

MOBILE NO. :

_________________________________________________________

E-MAIL:

_________________________________________________________

2. SEX:
3.
3.
3.
3.

Male

DATE OF BIRTH & AGE

(i)
(i)
(i)

4. PLACE OF BIRTH
5. a)

Female

Village / Town

COMMUNITY :

Age as on 1st July

Years
Months
Days

Date of Birth (Christian Era)

Date
Month
Year

ST

SC

District
MBC

State
BC

OC

Only in respect of person belonging to Tamil Nadu

b)

RELIGION:

6. NATIONALITY

Hinduism

Christianity

Islam

Others

specify.....................

..................................................................................................

7. a)

Fathers / Guardian Name

...............................................................................................

b)

Occupation of Father / Guardian

...............................................................................................

c)

Permenant Residential Address of Parent

...............................................................................................
..................................................................................................
..................................................................................................

d)

Telephone Number / Mobile No.

...................................................................................................

e)

Department / Office address :

...................................................................................................
...................................................................................................

f)

Office Telephone Number :

...................................................................................................

8.

Annual Income of Parent/Guardian(Rs.)

...................................................................................................

9.

Do you require Hostel accommodation ?

...................................................................................................

10.

Details of Academic Performance:

Institution / College :Degree

:-

Branch

:-

University / Board

:-

Year of Passing

:-

Semester

% of Marks Semester % of Marks

Overall %
*Overall % must be based on Marks / Grade obtained in all the semester Exams completed till now.
11.

Indicate the status of your Qualifying Exam

Results Awaited

Probable date of result

Results Available
12.

Year of Experience (if applicable)

Teaching..........................................

13.

Industry.................................................

Professional Experience after obtaining the qualifying degree

S.No.

Name of the Organisation

Designation

Period
from

to

No. of
Years

14.

Whether Sponsored of Not?

15.

Extra curricular Activities

Yes

No

I declare that the information furnished is correct to the best of my knowledge. I confirm that I have read the instructions
given in the first page of this application and I assure that I will abide by the rules and regulations of the University.
Place : ....................................................
Date

: ....................................................
Signature of Applicant

Note :- Completed Application should be sent to THE DIRECTOR (ADMISSIONS), B.S. Abdur Rahman University,
Vandalur, Chennai - 600 048.

FOR OFFICE USE ONLY

4.

Qualifying examination

Diploma(Branch)
/ Degree...............................................................
(Branch) .............................................
Degree
Year of passing ...............................................................
......................... %
SC

C lass

5.

Community

ST

MBC/DNC BCBC(Muslims)
Others BC

Others

6.

Application form complete

Yes

7.

Particulars verified by

Name ..................................... Signature ........................

8.

Originals Verified by

Name ..................................... Signature ........................

9.

Countersigned by

Name ..................................... Signature ........................

10.

Reasons in case of rejection

..............................................................................

No

......................................................................................
Name .................................. Signature ....................

Countersigned by
Registrar