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Application form for VITEEE - 2013

Full Name : ARPIT SHRINGI Application. No. : 2013012259

Date of Birth : 26/08/1995 Gender : MALE

Religion : Hinduism Nationality : Indian

Community : General/OC Mother Tongue : Hindi

Native State : Madhya Pradesh Mode of Study : Regular

Landline No. : 0734 - 2512274 Mobile No. : 9425195627

Parent name : SURESH KUMAR SHRINGI Hostel : Yes

Choice of Campus : Vellore Email ID. : skshringi@yahoo.co.in

Qualifying Exam : 12th Class Month & Year Passing : Apr - 2013

Exam Roll.No./Reg.No. : Testcity : UJJAIN

Permanent Address : A 36/17, MAHANANDA NAGAR,UJJAIN,Ujjain,Madhya Pradesh,456010.

Name of the School : AADHARSHILA ACADEMY

Address of the School : SANWER ROAD, UJJAIN, Ujjain,Madhya Pradesh, 456010.

DECLARATION

I solemnly and sincerely affirm that I am an Indian National and that all particulars furnished

by me in this application form are true and correct . I have not concealed any information.However, in the event of any information being found to be incorrect, fraudulent or untrue,either before or after the examination or after my admission to the programme, I understandthat I am liable to face criminal prosecution and the management can claim all authority tocancel my candidature / selection or admission as the case may be and I would have to foregomy seat and the fees.

I agree to abide by the rules and regulations governing the examination as well as the rulespertaining to the refund of tuition and hostel fees contained in the brochure.

I further undertake to submit all the required certificates as per the rule, either at the time ofinterview or during the admission process, failing which I understand that I would have toforego my seat and the fees.

Date :

Place :

Signat ure of Parent / Guardian Signature of t he App licant

PASTE FIRMLY YOURRECENT COLOUR

PHOTOGRAPH OF GOODQUALITY

(SIZE 3.5 X 4.5 CM)

PLEASE WRITE YOUR NAMEAND

APPLICATION NO. ON THEBACK SIDE OF THE

PHOTOGRAPHBEFORE AFFIXING.

Payment Acknowledgement Copy VIT ONLINE APPLICATION SALE

Payment Option Made :- NetBanking / Credit Card / Debit Card.

Bank Reference No. : 201212099400273 Transaction No. : 58740339

Applicant Name : ARPIT SHRINGI Application No. : 2013012259

Contact No. : 9425195627 Transaction Date : 09-12-2012 07:34:00

Application Fee : 900.00 Service Charge(including service tax): 34.00

Total Amount : 934.00 (Rupees Nine Hundred And Thirty Four Only).

Note :1.It is mandatory that the candidate should send the hardcopy of the application form to the address of theDirector - UG Admissions,VIT University, Vellore -632014,Tamil Nadu.2.Candidate should retain the photocopy of the application form.

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VITEEE - 2013 BY REGISTERED POST / SPEED POST ONLY

Application. No. : 2013012259

Applicant Name : ARPIT SHRINGI

ToMode of Payment Demand Draft ( DD ) : Net Banking / Credit card / Debit card :

THE DIRECTOR - UG ADMISSIONS,

VIT University,Vellore - 632014,Tamil Nadu,INDIA.

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The Above address may be pasted on the envelope.

Student Copy

PLEASE INSERT THE APPLICATION FORM IN THE ENVELOPE IN SUCH A MANNER THAT THE

BARCODE ON THE APPLICATION FORM IS NOT FOLDED.

CHECKLIST FOR THE CANDIDATE

1.Tick the box if you have enclosed the following documents:

a. Completed Application Form with your signature.

b. Completed Application Form with your parent's / Guardian's signature.

c. Your color photograph (of size 3.5 cm x 4.5 cm) affixed on application appropriately.

d. Have you entered your correct Date of Birth.

2.Retain a photocopy of the completed application form with you.

3.Send your application form to the VIT as mentioned on the address slip