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Application form for VITEEE - 2013

Full Name : KUSH KUMAR Application. No. : 2013047175

Date of Birth : 10/03/1995 Gender : MALE

Religion : Hinduism Nationality : Indian

Community : General/OC Mother Tongue : Gujarati

Native State : Gujarat Mode of Study : Regular

Landline No. : 06542 - 269891 Mobile No. : 8986871502

Parent name : KETAN CHAWDA Hostel : Yes

Choice of Campus : Vellore Email ID. : ketan64chawda@gmail.com

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

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

Permanent Address : QUARTER NO 1144, SECTOR 6A,BOKARO STEEL CITY,Bokaro,Jharkhand,827006.

Name of the School : DELHI PUBLIC SCHOOL

Address of the School : SECTOR 4, BOKARO STEEL CITY, Bokaro,Jharkhand, 827004.

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. : 0386486620 Transaction No. : 59698309

Applicant Name : KUSH KUMAR Application No. : 2013047175

Contact No. : 8986871502 Transaction Date : 20-12-2012 10:40:23

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. : 2013047175

Applicant Name : KUSH KUMAR

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