Form No. Rs. 300/- FACULTY OF ENGINEERING & TECHNOLOGY AGRA COLLEGE, AGRA Registration/Admission Form (2015 - 2016) For admission in B.Tech. Ist Year & Lateral Entry in B.Tech. IInd Year Affix Recent Passport Size Photograph 1. Name of the Student (in Capital Letters) : __________________________________ 2. Father’s Name : __________________________________ 3. Mother’s Name : __________________________________ 4. Email ID (compulsory) : __________________________________ 5. Date of Birth : (Attach copy of High School Certificate) 6. Nationality : 7. Gender : Male 8. Category (Attach copy of caste certificate) : Gen 9. Permanent Address : ________________________________________________________________ Ph. No. (With STD Code) : _________________________________________Pin Code _______________ Day Month Year ________________________________________________________________ Female OBC SC ST Mob. No. _________________________ 10. Correspondence Address : ________________________________________________________________ Ph. No. (With STD Code) : _________________________________________Pin Code________________ Mob. No. _________________________ Details of Bank Draft : Draft No. Name of Bank Amount Date (Draft should be in favour of “Principal, Agra College, Agra Payable at Agra.) 11. UPSEE/JEE Main Rank & Roll No. (Attach copy of rank Card) : ________________________________________________________________ 12. Year & Semester : ________________________________________________________________ 13. Fill in the preference of branch 1 as 1st choice and 4 as last choice. 14. Computer Science & Engineering Mechanical Engineering Electronics & Communication Engineering Civil Engineering Education Qualification (Attach copy of Mark sheets) : (All columns are compulsory to be filled) Sl. Name of No. Examination 1. High School 2. Inter (10+2) 3. Diploma/B.Sc. (For B.Tech. II Year) 15. Name of Institute & Board Want hostel facility Note :- % age in PCM/PMC in (10+2) Yes Roll No. Max. Marks Marks obtained Year of Passing Remark No PCM (Physics, Chemistry & Maths) PMC (Physics, Maths & Computer) (can apply only for Computer Sci. & Engg.) Note :- All admission will be done as per UPTU/UPSEE norms. DECLARATION I hereby declare that all the entries made by me in the form are correct. I shall abide by the rules and regulations of the college and follow the rules of discipline of the college. Also I shall not take part in ragging in any form. Further, if any information is found wrong, I am ready to face any sort of punishment/cancellation of my admission. _______________________ Date :- ________________________ (Signature of Parent/Guardian) _______________________ (Signature of Student) ………………………………………………………………………………………………………………………….…………… Form No. :- ____________ (for Office use only) Admitted in : ____________________________ __________________________ Signature of Admission Officer Date of Admission in faculty : _______________
© Copyright 2024