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 : _______________