Bhilai Institute of Technology, Raipur(Seth Balkrishan Memorial)

Inspiring genera�on Inspiring Technology[Approved by AICTE, New Delhi, Affiliated to CSVTU Bhilai. Consented by CG Govt.]

APPLICATION FORM

B.E.

M.Tech.

DIPLOMA

B.E.

PROGRAMMES OFFERED

60SEATS

M. TechDIPLOMA COURSE

POST GRADUATION COURSE

UNDER GRADUATE COURSES (ENGINEERING)

18SEATS

30SEATS

30SEATS

DIPLOMAIN EEE

DIPLOMA INMECHANICALENGINEERING

MECHANICALENGINEERING

COMPUTERSCIENCE

CIVILENGINEERING

60SEATS

120SEATS

ELECTRONICS &TEL. COMM. ENGG

60SEATS

60SEATS

ELE. & ELECTRONICSENGINEERING

INDUSTRIAL SAFETY

Bhilai Institute of Technology, Raipur

COURSE AND BRANCH : __________________________________________________

1. Name of the Candidate : __________________________________________________

(As men�oned in the qualifying

examina�on cer�ficate)

2. Date of Birth :

3. Gender : Male Female

4. Blood Group : __________________________________________________

5. Religion : __________________________________________________

6. Na�onality : __________________________________________________

7. Caste : ST SC OBC GEN

8. Mother Tounge : __________________________________________________

9. Name of the Father : __________________________________________________

10. Father’s Occupa�on : __________________________________________________

11. Name of the Mother : __________________________________________________

12. Mother’s Occupa�on : __________________________________________________

13. Aadhar No. : __________________________________________________

B.E M.TECH DIPLOMA

D D M M Y Y Y Y

Affix arecent

passportsize color

photo

14. Address for Communica�on : Permanent Address Present Address

____________________________________ ______________________________________

____________________________________ ______________________________________

____________________________________ ______________________________________

Pin Code : Pin Code :

Phone : ______________________________ Phone : __________________________ with STD Code with STD Code

(Seth Balkrishan Memorial)

15. Hostel Accomoda�on : Required Not Required

16. Details of Qualifying Entrance Examina�on :

Entrance Name Roll No. Category Rank Overall Rank Marks Obtained

17. Marks obtained in the Board Examina�on

Exam Board/University School / College Name Year %

SSC

HSSC

DECLARATION OF THE CANDIDATE

• I Solemnly affirm that I have gone through the prospectus of the “Ins�tute Containing” the rules and regula�on.

• I undertake that I shall not par�cipate in any kind of demonstra�on/agita�on/strike etc.

• I hereby undertake that I will neither get involved in ac�vites directly or indirectly nor cause any sort of mental physical harassment to my juniors. The informa�on provided by me in this applica�on form are true and correct to the best of my knowledge.

• I am fully aware of the rule that once admi�ed to the ins�tute, annual fee is not refundable in any circumstances and I shall have no claim on it except on cau�on deposit.

• In case any infora�on/cer�ficate at any stage is found incorrect, my Admission may be cancelled without no�ce and I will not have any claim for the loss whatsoever it may be.

_____________________________ Father/Gaurdian’s SignatureName : Place :Date :

_____________________________Candidate’s Signature Name : Place :Date :

FOR OFFICE USE ONLY

Payment Type Amount MR. No. with Date

Prof. Incharge Admission Account Officer Principal

1. Original and photocopies of counselling allotment - 2 copies

2. DVC Form - 1 copy

3. PET/JEE Marksheet - 2 photocopies

4. 10th & 12th Marksheets - 4 photocopies

5. Original Migra�on Cer�ficate + 2 photocopies (Only for CBSE students and Other Board students)

6. Original Transfer Cer�ficate + 2 photocopies

LIST OF ENCLOSURES7. If any gap is there (from 12th passing to as on date) Original Gap Cer�ficate + 2 photocopies

8. Colour Passport Photographs - 12 photos

9. Domicile & Caste Cer�ficate - 2 photocopies10. Parents Current Year Income Cer�ficate - 2 photocopies

11. Aadhar Card - 2 photocopies

Address : Near Kendri Rly. Stn., Abhanpur Road, Atal Nagar (Naya Raipur) Dist.- Raipur 493 661 (C.G.) INDIA

Ph. : 9752065555, 7471116575Email : admission@bitraipur.ac.in

www.bitraipur.ac.in

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