CENTRAL INSTITUTE OF TECHNOLOGY KOKRAJHAR (A Centrally Funded Institute under Ministry of HRD, Govt. of India) BODOLAND TERRITORIAL AREA DISTRICTS :: KOKRAJHAR :: ASSAM :: 783370

Website: www.cit.ac.in

ADMISSION WITHDRAWAL FORM FOR DIPLOMA/B. TECH /B. DES STUDENTS A.

PERSONAL DATA:

(1) Name of the Candidate: (Capital Letters):- _________________________________________________ (2) Father’s Name: ______________________________________________________________ (3) Mother’s Name:- ______________________________________________________________

Paste a recent passport size color Photograph

(4) Home Address: Vill/Town:…………………………………………..……...P. O:……………… Ward No:…………Dist:……………………………………State:…………………………PIN:……………

Students Tel No. (M)……………………………………… (Email ID)………………………………………………………

(5) Region (AI/NE/BTAD/J&K/Other):- _____________________________________ (6) Religion:- (Hindu/Muslim/Christian/Other):- _______________________________ (7) Category (SC/ST/OBC/OPEN/PH) :- _____________________________________ (8) Are you a Boarder of CIT Hostel? If Yes, Name of Hostel:- __________________________________________________ Wing No:- ______________________________Room No:- _______________________________ (9) Mention current Year & Semester:- _________________________________ (10) Whether: Regular Student/ Year Back Student:- ________________________ (11) Date of Birth :( DD/MM/YY):- ______________________________

(12) ENROLMENT DATA: (i)

Admitted into (Diploma/B. Tech/B. Des):- _____________________________

(ii) Selected through/in: (Merit/Waiting List/JEE (Main)/UCEED/PAT/CITLET):- __________________________________ (iii) Branch:

Year:

Roll No:

(13) Bank Details:(i)

Name of the Student:- ________________________________________________

(ii)

Name of the Bank:- __________________________________________________

(iii)

Branch Name:- ______________________________________________________

(iv)

IFS Code:- __________________________________________________________

(v)

Account Number: ___________________________________ DECLARATION BY THE CANDIDATE:

I,……………………………………………………………………………………………………..…………………………,hereby, declare that the information given above is true to the best of my knowledge. I have received all original documents in good condition which was submitted by me at the time of admission. I have no objection to transfer my refundable admission fees into the above mentioned bank account after necessary processing fee deduction by the CIT Kokrajhar authority.

Date:

Signature of the Student

CENTRAL INSTITUTE OF TECHNOLOGY KOKRAJHAR (A Centrally Funded Institute under Ministry of HRD, Govt. of India) BODOLAND TERRITORIAL AREA DISTRICTS :: KOKRAJHAR :: ASSAM :: 783370

Website: www.cit.ac.in

DECLARATION BY THE PARENT/GUARDIAN:

I,……………………………………………………………….father/mother/guardian of Sri/Ms. ……………………………………………… hereby, declare that the statements furnished by my son/daughter are true to the best my knowledge and belief. I have no objection for withdrawing the admission of my son/daughter from CIT Kokrajhar. I shall not interfere any decisions opted by the Institute for deducting the admission processing fees and shall have no objection for transferring the remaining amount to his/her account.

Date:

Signature of the Parent/Guardian

For office use only I have checked and found liabilities/no liabilities against the student.

Signature of the Librarian/Asst. Librarian with date ______________________________________________________________________________________________________________________ I have checked and found liabilities/no liabilities against the student.

Signature of the Member Secretary, Hostel Management Committee/Chief Hostel Warden with date I have checked and found liabilities/no liabilities against the student.

Signature of the Accountant/Assistant Registrar (Finance) with date I have checked and found liabilities/no liabilities against the student.

Signature of the Examinations Superintendent with date I have checked and found liabilities/no liabilities against the student.

Signature of the Member Secretary, Admission Committee with date

Approved/Not Approved

Director/Registrar CIT Kokrajhar