Dr. V. P. Shetkari Shikshan Mandal’s

Padmabhooshan Vasantraodada Patil Institute of Technology, Budhgaon, Sangli-416304

For college use only

Form No:

Course Admitted to:

Division: Roll No:

Admission date:

/

College Code: Pleas e paste a passport Size (35 mm X 45 mm) Photograph here,

/

Do NOT staple.

Kindly read important notes before filling-in form: 1. Use black ink to f ill in the form and Do NOT overwrite. 2. Fill in all fields in CAPITAL letters only. 3. Strike-off whichever is NOT applicable. E.g. If you are a Male :-> Gender: Male / Female

Photo o should not Exceed the borders.

Course applied for

BA / B Com / BE / ME

Course Part or Semester applied for

1/2/3/4

 Student should sign strictly inside this box only with black ink

Applying for Concession EBC / SC / ST / NT / OBC / SBC / PTC / STC / Freedom Fighter / Ex Service Man Admitted against which Category : Open / Reserved

If Reserved, Specify:

1. Personal Information Section Last Name

First Name

Middle Name

Name of the Student: (In case of changed name, write current name)

Name of the Student: (In local language) (Devanagari)

Name of the Student: (As printed on std. 10 Passing Certificate)

Father’s/Husband’s Name: Mother's Name: Previous name of the Student: (In case of changed name)

Reason for name change: Willingly / After Marriage Date of Birth (DD/MM/YYYY): / / Place of Birth: Religion: Student’s location Category: Rural/ Urban/ Tribal Address for Correspondence State: District:

Marital Status: Unmarried / Married/Divorced/ Widowed/Deserted Gender: Male / Female Blood Group (with Rh): Citizen of (country name):

Tehsil:

Address

City/Town/Village: PIN Code

(House no, street/area/suburb etc.)

Permanent Address [Write only if different than ‘Address for Correspondence’] State:

District:

Tehsil:

Address

City/Town/Village: PIN Code

(House no, street/area/suburb etc.)

Contact Details Phone # 1: STD Code: Mobile number:

Phone No:

Phone # 2: STD Code: Email ID: -1-

Phone No:

2. Legal Reservation Information Section Domicile of State: Caste:

Category: If Reserved: Open / Reserved SC / ST / DT(A) / NT(B) / NT(C) / NT(D) / OBC / SBC Sub-Caste: If Physically Challenged: Visually Impaired / Speech and/or Hearing Impaired / Orthopedic Disorder or Mentally Retarded

3. Social Reservation Information Section [Check () whichever is applicable, write name of supporting document attached, in section 6.] Ex-Serviceman/Ward of Ex-Serviceman Member of Project Affected Family Active-Serviceman/Ward of Active-Serviceman

Member of Earthquake Affected Family

Freedom Fighter/Ward of Freedom Fighter

Member of Flood / Famine Affected Family

Ward of Primary Teacher

Resident of Tribal Area

Ward of Secondary Teacher

Kashmir Migrant

Deserted/Divorced/Widowed Women

4. Guardian Information Section Occupation of the Guardian: Service / Business / Profession / Farmer / Laborer / Retired

Annual Income of the Guardian (last financial year) (Rs.):

Relationship of guardian with applicant: Phone No.: 5. Educational Details Section [Write ‘YES’ in last column, against the qualifying examination, on basis of which you are seeking admission to the said course write NO in front of other examinations] Please Note: 10th Details are mandatory in any case Last College Attended: Year: Roll No.: Name of Examinati on

Name of Board /University

Name of School/Colle ge

Date of Passing (DD/MM/ YYYY)

Examinati on Seat No. (Last)

Std 10th Std 12th

6. Selected/Opted Papers Section [Write paper codes or Paper Name only, in the boxes] 1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7.

7.

8.

8.

-2-

Degree / Passing Certificate No.

Grade / Total Marks Obtained

Out of

Qualifying Examination? (YES/NO)

7. Attached Documents and Certificates Section Sr. No.

Name of Document/Certificate

Original / Attested True Copy

1.

Passing Certificate of Std. 10th

Attested True Copy (Mandatory)

3.

Passing Certificate of Std. 12th / Statement of Marks of Std. 12th Leaving Certificate

4.

Certificate of Caste with Category

Attested True Copy

5.

Non Creamy Layer Certificate Affidavit for changed name/ Marriage Certificate / Govt. Gazette Domicile Certificate Domicile Certificate

Attested True Copy

2.

6. 7. 8. 9. 10.

Attached (Yes/No)

Attested True Copy Original

Original Attested True Copy Attested True Copy

8. Other Information Section Mother Tongue:

Employment Status: Employed / Unemployed Would you like to apply for Hostel: Yes / No

Do you wish to join NCC / NSS : Yes / No

Hobbies, Proficiency and Other Interests: Games and Sports participation: Level (e.g. college/state/national/international etc.): Personal Identification Marks: 1.

2.

9. Declaration by Student I hereby declare that, I have read the rules related to admission and the information filled in by me in this form is accurate and true to the best of my knowledge. I will be responsible for any discrepancy, arising out of the form signed by me and I undertake that, in absence of any document the final admission will not be granted and/or admission will stand cancel. I am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that I will abide by all the rules and regulations of the said Act. Place: Date: Signature of the student:

10. Declaration by Guardian I have permitted my son/daughter/ward to join your college. The information supplied by him/her is correct to the best of my knowledge. I have acquainted myself with the rules and fees, dues to my son/daughter/ward and to see that he/she observes. Place: Date: Signature of the Guardian:

11. For College/Institute Use Only Designation

Remarks / Particulars / Recommendations

Signature and date

Admission Clerk Admission Committee Accountant/Cashier

Cash Received: Rs.

Receipt No.:

Registrar/Office Superintendent Principal/Director Note: Student MUST retain photocopy of completely filled in admission form (both pages) for future reference. Available information in this form will be required to activate his/her account on Digital University Portal. -3-

Form No.: ________

UNDERTAKING From: ________________________________ ________________________________ ________________________________ ________________________________ Date: ____ / ____ / __________ To, The Principal, PVPIT, Budhgaon.

I, the undersigned _______________________________________________ hereby undertake that, any increase in the fees as approved by Shikshan Shulk Samiti, Govt. Of Maharashtra, will be remitted by me in due time as and when declared. Hence this undertaking is given.

Yours Faithfully,

Signature of Parent/ Guardian

Signature of the Student

(Name :____________________)

(Name :__________________)

-4-

Form No.: ________ Dr. V. P. Shetakri Shikshan Mandal’s

P. V. P. Institute of Technology, BUDHAGAON ADMISSION TO FIRST / SECOND / M.E DEGREE COURSE IN ENGINEERING (2014-2015)

(Round I /II / III / IL / A-CAP) 1.

Name of the Students

______________________________________

(As appeared on XII Mark sheet)

2.

ID No.: _________________

Password: _____________________________

3.

Course:

______________________________________

4.

Category:

____________

5.

Physically handicapped:

Yes / No

(If yes, attach certificate)

6.

Defense:

Yes / No

(If yes, attach certificate)

List of Documents Submitted Open/Common to all candidates 1. Student’s Allotment letter 2. JEE Score Card

All reserved category (SC/ST/VJ.DT-A/NTB/NT-D/OBC/SBC) 1. Caste Certificate

Only( VJ.DT-A/NTB/NT-D/OBC/SBC)

1. * Non-Creamy layer Certificate

TFWS

1. Income Certificate

1. Caste Validity

3. XII Mark sheet 2. Proforma H*on 100/Stamp paper 4. X Mark sheet 5. School leaving Certificate (*who have not 6. Nationality Certificate submitted caste validity 7. Performa I certificate )

(*For the year 2012-2013 drawn after 31st march,2012)

(* Below 4.5 lakh)

Date: Remark:

Signature of the Candidate

Signature of the Scrutiny Officer: -5-

Form No.: ________ UNDERTAKING Date: To, The Principal, P.V.P.I.T., Budhgaon.

I hereby undertake to submit the following original certificates within four days, failure to which my admission will be cancelled.

Certificates: 1. _____________________________________________ 2. _____________________________________________ 3. _____________________________________________ 4. _____________________________________________ 5. _____________________________________________

Parent’s /Guardian Signature (Name :________________)

Student’s Signature (Name :________________)

Phone No:

Class : Branch:

-6-

Form No.: ________ Dr. Vasantraodada Patil Shetkari Shikshan Mandal’s

PADMBHOOSHAN VASANTRAODADA PATIL INSTITUTE OF TCHNOLOGY, BUDHGAON.

(DEGREE WING) Student’s Name: __________________________

Rupees

Qty.

Amount

1000 X

Branch: _____________

Class: ____________

500 X

Category: ____________

Date: ____________

100 X 50 X

Amount: _____________

20 X 10 X

Payment Mode: Cash / DD

5X

DD No. _______________ Date: ____________

2X 1X

Bank Name: _____________________________ Total

Student’s Signature

In charge

Admission In charge

Form No.: ________ Dr. Vasantraodada Patil Shetkari Shikshan Mandal’s

PADMBHOOSHAN VASANTRAODADA PATIL INSTITUTE OF TCHNOLOGY, BUDHGAON.

(DEGREE WING) Student’s Name: __________________________

Rupees

Qty.

Amount

1000 X

Branch: _____________

Class: ____________

500 X

Category: ___________

Date: ____________

100 X 50 X

Amount: ____________

20 X

Payment Mode: Cash / DD

10 X 5X

DD No. _______________ Date: ____________

2X

Bank Name: _____________________________

1X Total

Student’s Signature

In charge -7-

Admission In charge

Form No.: ________

Conduct and Discipline

I fully understand that the Principal of the college has a right to expel me from the college for any infringement of the rules of conduct and discipline prescribed by the college or university or Government.

Condition of minimum attendance: I am fully aware that, I will not be allowed to appear for the examination if I do not attend minimum 75% classes of theory, practical, drawing etc. I am also aware that I will not be allowed to appear for the examination, if I fail to submit satisfactorily all the assignments, jobs, journals, drawings, reports as may be specified by the University within stipulated time limit.

Parent’s Guardian Signature

Student’s Signature

(Name :________________)

(Name :________________)

-8-

Form No.: ________ UNDERTAKING (As per the provisions of anti –ragging verdict by the Hon’ble Supreme Court closed herewith)

I, Mr. /Ms. ............................................................................, Roll No.: ………………….., Program: .................................... Student of ……………………………………… do hereby undertake on this day……………….…month…………year …………………………, the following with respect to above subject. 1) That I have read and understood the directives of the Hon’ble Supreme Court of India on anti-ragging and the measures proposed to be taken in the above references. 2) That I understand the meaning of Ragging and know that the ragging in any punishable offence and the same is banned by the Court of Law.

form is a

3) That I have not been found or charged for my involvement in any kind of ragging in the past. However, I undertake to face disciplinary action/legal proceedings including expulsion from the Institute if the above statement is found to be untrue or the facts are concealed, at any stage in future. 4) That I shall not resort to ragging in any form at any place and shall abide by the rules/laws prescribed by the Courts, Govt. of India and the Institute authorities for the purpose from time to time.

Signature of Student

I hereby fully endorse the undertaking made by my child / ward.

Signature of Mother / Father and or Guardian

Witness:

-9-

Form No.: ________

UNDERTAKING From: ________________________________ ________________________________ ________________________________ ________________________________ Date: ____ / ____ / __________ To, The Principal, PVPIT, Budhgaon. R/Sir, With reference to the discussions regarding FIRST/SECOND (Direct) year engineering course for the year 2013-2014, I hereby request you to admit me provisionally to F.E. /S.E. (D)/M.E Course. MY CHOICE OF BRANCH IS AS UNDER: 1.

________________________________________

2.

________________________________________

3.

________________________________________

4.

________________________________________

I request you to admit me to suitable Course PROVISIONALLY as per the merit, subject to approval from D.T.E. M.S.Mumbai. I understand that Shikshan Shulk Samiti, Govt. of Maharashtra has given interim fee structure for the Academic Year 2013-2014. Revision in Fee structure if any, by Shikshan Shulk Samiti will be binding on me and I will arrange to pay the requisite Fees accordingly. Further, I know, if the Govt. of Maharashtra, DTE, Mumbai revises the Admission Procedures rules & regulation for the said Degree Course, and due to this, if I am not eligible for the said Admission in your college, I will not claim any Admission for the Courses stated above. If admission is cancelled for any valid reason, I agree for the deduction of processing fees as decided by the Management/ College. Yours Faithfully,

Parent’s/Guardian’s Signature (Name :__________________)

Student’s Signature (Name :________________) -10-