BIRLA INSTITUTE OF TECHNOLOGY

(Deemed University)

For office use only

Mesra, Ranchi 835 215, Jharkhand

Application Form For B.E. / B. Arch 2013
at BIT Mesra
SESSION 2013 2014
Application for admission to B.E. 2013

B. Arch 2013

Based on Overall AIR in JEE-MAIN 2013 through Institutional Counselling for BIT Mesra
Please use one form to apply for only ONE programme either B.E. or B. Arch
PLEASE WRITE IN CAPITAL LETTERS, PUT NUMBERS OR TICK () THE BOXES AS REQUIRED

1.

Full Name of Candidate: ______________________________________________

2.

Fathers Name: _____________________________________________________

3.

Mothers Name:_____________________________________________________

4.

Date of Birth: in dd/mm/yy format __________/__________ /__________

5.

Age on 1/10/2013__________years __________months __________days

6.

Sex: Male

7.

JEE-MAIN 2013 Roll No:_______________________

8.

JEE-MAIN 2013 Application No _____________________

9.

Overall AIR in JEE-MAIN 2013___________10. State of Eligibility _______________

11.

Category: [Tick whatever is applicable]

(a) GEN

12.

Female

(b) SC

(c) ST

(d) PH

Preferences of branch (see notification)

(a)_______________(b)_________________(c)_________________

13.

Educational record:

Examination

Board /
University

Year of
passing

Percentage
#
of Marks

No of
$
Attempts

Subjects**

Class 10 /
Matriculation exam
Class 12 / I. Sc. / or
equivalent (specify)

14.

School/College from where you have completed Class 12 / Qualifying Examination

QUALIFICATION

NAME AND ADDRESS OF SCHOOL / COLLEGE

WITH TELEPHONE NUMBER

STATE

Instructions: Please ensure that you fulfill all the eligibility criteria before filling the form
PLEASE DO NOT WRITE MR. / SHRI / MISS/ / MS/ MRS. / SMT IN SPACE FOR NAME
Enclose photocopies of marksheets of Class 10, Class 12, Admit card and Score card of JEE-Main
2013 and Caste / Special Category certificates. Write your Name, programme applied for and
telephone number, on the back of these papers.
$ Write 1 if cleared in one attempt, etc
** Use abbreviations such as ENG, CHEM, MATH, PHYS, BIO, etc

15. Address for communication including your full name:

Address for communication (should be valid till Dec 2013)

Name: ___________________________________________

Paste recent colour

photograph here

_________________________________________________

Do not get the

photograph attested

_________________________________________________
City_________________________ Pin code_____________
STD Code________ Telephone Number________________
Mobile __________________________________________

Signature

16. Permanent Address: ________________________________________________

________________________________City_______________ Pin code____________
STD Code _______Telephone Number____________ Mobile ____________________
E-mail id: ___________________________________________________________
17. Details of Demand Draft attached for Rs.2,500/-(General) and Rs.1,500/- (SC/ST
candidates) in favour of Birla Institute of Technology, payable at Ranchi:
Demand Draft No.___________________________ Date of Issue: _________________
Issuing Branch_________________________________ City ______________________
18. Declaration: I hereby declare that all the information given by me in this application is
true and correct to the best of my knowledge and belief. I also note that if any of the above
statements are found to be incorrect or false or any significant information or particulars
have been suppressed or omitted there from, I am liable to be disqualified. If selected my
admission will be liable to be cancelled without notice or compensation in lieu of notice.
I hereby permit / do not permit (delete one) the Institute to use, display or transfer any of the
details furnished by me in this form for any other purpose, except for complying with the
admission formalities.
Signature of Candidate: ______________________Date: __________________
Countersigned by Parent: ______________________Date: __________________
Enclosures required: Photocopies of following certificates must be attached to application form:
1.
2.
3.
4.

5.

6.

Admit Card & Rank Card of JEE-MAIN 2013

Pass Certificate & Mark Sheet of Class 10
Mark Sheet of Class 12
Caste Certificate (if applicable) in proper format and issued by appropriate authority of rank not less
than SDO
PH Category Certificate (if applicable) issued by appropriate authority, in JEE-MAIN 2013 / CSAB
format clearly specifying that candidate is capable of carrying out all activities related to theory and
practical work including workshop and drawing in the Architecture / Engineering courses without any
special concessions and exemptions
School Leaving Certificate and Migration Certificate

_________________________________________________________________________________
For office use only
Eligible
Not Eligible
In case ineligible, please specify reasons: _____________________________________________

Signature of verifying Officer/ Staff