Admission FormSession 2020-21

Saroj Institute of Technology & Management, Lucknow (Code -123)

Shivdan Singh Institute of Technology & Management, Aligarh (Code-007)

Saroj Institute of Management Technology, Lucknow (Code-529)&

Lucknow Institute of Pharmacy (Code-572)

Saroj College of Engineering and Polytechnic (Code-2704)

Saroj collage of Pharmacy, Lucknow (Code-2031)

PastePassport SizePhotograph

SAROJ EDUCATIONAL GROUPOne of North India’s Largest Educational Group

( The appropriate one )

A) B.Tech. Course : CS IT EC EN ME BT CE BM ENV EE AG

1. B) M.Tech Course : ________________________________________________________________________

C) Pharmacy Course: D.Pharm B.Pharm M.Pharm

D) Management Coures BBA MBA

E) Diploma: CE ME CS EE EC AG

F) Computer Application: BCA MCA

G) Education B.Ed

Application No. _________ AADHAAR No.:________________________________________________________________________________

UPSEE Roll No.:______________________________________________________________________________

UPSEE Rank : ________________________________________________________________________________

9.Permanent Address: _________________________

______________________________________________

______________________________________________

Phone No.: ___________________________________

Mobile No.(S): ________________________________

Email Id: _____________________________________

10.Nationality: ________________________________

Postal Address (For correspondence)____________

______________________________________________

______________________________________________

Phone No.: ___________________________________

Mobile No.(S): ________________________________

Email Id: _____________________________________

Pin Code: Pin Code:

11.Category: SC/ST/OBC/General (Tick the appropriate)

2.Name ( In Capital Letters): ___________________________________________________________________

4.Father’s Name: _____________________________________________________________________________

5.Mother’s Name: ____________________________________________________________________________

6.Father’s Occupation: ____________________________ if Service (Govt./Pvt.): _______________________

7.Approx Annual Income: _____________________________________________________________________

8.Name & Occupation of Guardian: ____________________________________________________________

3.Date of Birth: Aadhaar No.:

11.Educational Qualification : Please attach attested copies of marksheet for each examination

Cited below:

ExaminationPassed

Name ofInstitution

Year ofPassing

Division % Mark Subject

10th

10+2

Graduation/Diploma

Declaration by the Applicant

I hereby agree that I shall pay full fee prescribed/revised for the course by the Goverment/Institute Authorities.I hereby agree not to make any loss or damage to books, apparatus, furniture and any other property belonging to the institute by carelessness/negligence on my part.I hereby agree that I shall follow and adhere to all hostel rules and regulation promulgated by the hostel or institute authorities form the hostel or even from the institute as may be deemed fit by the authorities.I am aware that ragging, smoking and drinking alcohol is strictly prohibited in the campus and the hostels and I assure that I shall abide by the same.I hereby authorize the Institute to use any deposits made by me to the Institute for the development work related to the institute.I understand that association whether active or passive with any unlawful organization is for bidden. All the particular stated in the application are true to the best of my knowledge and belief. I hereby declare that I have read and understood the rules and regulation of the institute and I promise to abide by the rules and discipline of the institute. Should it however be found that any information furnished is untrue. I realize that I realize that I am liable for criminal prosecution and expulsion from the Institute.If I could not complete the course under any circumstances or withdraw from the course in between, no part of the once fee deposited along with security will be refunded.I understand that once fee deposited will not be refunded by institute after the admission.I hereby agree that all disputes are subject to Lucknow jurisdiction.

Date: __/__/____

Undertaking by the Parents/Legal Guardian

In the event of the above applicant who is my son/daughter/ward being admitted to the institute I hereby give an undertaking to pay regularly all his/her dues to the institute, till his/her complection of the course of studies. I also undertake to be responsible for his/har character and conduct throughout his/her stay in the institute.

Signature of Applicant

Date: __/__/____ Signature of Applicant

Application No.

Name:

Fathrer’s Name:

Course:

Branch:

Fee Structures (per year/semester):

Fee deposited all the time of admission:

Remaining Fee:

Last date of depositing remaining fee:

Hoste/Bus:

Remark (if any)

Sign. of Student Sign. of Guardian/Parent

1. Name of Student: ___________________________________________________________________________

2. Branch: ___________________________________________________________________________________

3. Details of Reference: ________________________________________________________________________

Account Copy

Industrial Reference

Application No.:

a) Name: ___________________________________

b) Address (Resi): ___________________________

____________________________________________

____________________________________________

c) Phone:(R) _______________________________

d)Mobile No.: _______________________________

e) Phone (O): _______________________________

f) E-mail address: ___________________________

Name & Address of Company: ________________

____________________________________________

____________________________________________

Website/Mail: _______________________________

____________________________________________

a) Name: ___________________________________

b) Address (Resi): ___________________________

____________________________________________

____________________________________________

c) Phone: ________________________________(R)

d)Mobile No.: _______________________________

e) Phone (O): _______________________________

f) E-mail : ____________________________address

Name & Address of Company: ________________

____________________________________________

____________________________________________

Website/Mail: _______________________________

____________________________________________

Declaration Form

I _______________________________________________ Son/Daughter of _____________________________

of ______________________________________________________________________ Year ________________

Branch _____________________________________________________Roll No. __________________________

Enrolment No. _____________________________________________________ understand that

I shall be governed by the Norms regarding attendance as prescribed byDr. A.P.J. Abdul Kalam Technical University Lucknow ordinances as given below.

I hereby declare that I have not paid any money on account of Donation/Capitation feeto college for my admission.

Attendance

Every student is required to attend all the lectures, tutorials, practicals and otherprescribed curricular and co-corricular activities. The attendance can be condonedupto 25% on medical grounds or for other genuine reasons beyond the control ofstudent.

A further relaxation of attendance upto 15% for a student can be given by head ofInstitution/college provided that he/she has been absent with prior permission ofthe head of the Institute/college for the reasons acceptable to him.

No student will be allowed to appear in the end semester examination if he/she doesnot satisfy the overall average this attendance requirement of clause Nos. 3.1 and 3.2and such candidate (s) shall be treated as having failed and _______________

I understand that in case my attendance records do not clause No. 3.1 and 3.2 above. I maybe detained from appearing in the end semester Examination.

Residential Address: ________________________________________________________________________________________Phone No.: __________________________

Date: __/__/____Sign. of student

Declaration by Parents

I understand that my son/daughter/ward __________________ has to satisfy the normsregarding attendance as prescribed by Dr. A.P.J. Abdul Kalam Technical University’s ordinancesfor appearing in the University Examination. I will take special care to see that my ward satisfiesthat my ward satisfies that said University Norms.

Date: __/__/____ Sign. of Guardian/Parent