INDIAN INSTITUTE OF ENGINEERING SCIENCE AND TECHNOLOGY, SHIBPUR

HOWRAH - 711103, WEST BENGAL

APPLICATION FOR ADMISSION TO UG (DUAL DEGREE)/B-Arch/PG(M-Tech/M.Sc.),MTRP

(Use

mark where applicable)

MTRP

M-Tech.

Bachelor of Architecture

Dual Degree

ID NO. Allotted to the candidate

M.Sc.

For M-Tech: (Through GATE/NET/SLET)

( To be filled by the office)

MBA

For MBA: (CAT/CMAT/XAT with score)

GATE/NET Reg. No.

For Under Graduate Course:(Through JEE MAINS only)

JEE MAINS

(50%):

Rank

WB Domicile (50%):

Rank

GATE/NET Score
GATE/NET %

GATE Score valid up to

Month

Year

Branch: ...........................................................................................................................................

Or

Branch: .........................................................................................................................

Specialisation: ..............................................................................................................................
For M-Sc.:
IIEST M-Sc. Rank
(50% from CCMN & 50% from IIEST) CCMN Rank

Category of Candidature for all courses:

GENERAL

SCHEDULED CASTE

FOREIGN QUOTA

DEFENCE QUOTA

Branch: ...........................................................................................................................................
SCHEDULED TRIBE
OBC - A
PHYSICALLY DISABLED (PWD)
ANY OTHER
STATE NOMINEE
OBC - B
(Please state)

Caste Certificate issued by with No. & date: ...................................................................................................................................................

Name of the candidate (In CAPITAL LETTERS) :
Mr.

Ms.

Date of Birth:

Other

Month

Date

Year

Affix
Stamp size
colour photograph

First Name
Middle Name

(Self attested)

Surname
email address: ................................................................................................................................................................................................................................
Height
Female
Other
Weight
Mt./Ft.
Cm./inch
Adhar Card no.
Kg Male
Blood Group

Personal Identification Mark .......................................................................................................................................

Nationality .................................................... Religion: Hindu

Muslim

Christian

Sikh

Buddhist

Jain

Others

Name of the Guardian:

Tel.no.

Relation with the candidate

Address for communication:

Urban

Present / Permanent Address:

Flat no.

Rural

Nearest Rly. Station

Block no.

Village/City

Road/Street

Post Office
District

Police Station

Mobile no.

PIN
Country

State

Fathers Name

Mothers Name

Occupation

Occupation

Address

Address

PIN

Tel.no.

PIN
Rs.2,50,000 to Rs.5,00,000

Family Income: Less than Rs.2,50,000

Educational Qualifications:
Name of the Examinations

Tel.no.

Last Examination Passed

Name of the Board

Rs.5,00,000 and above

Last Examination appeared

Year of passing

Total obtained Marks with Percentage

Remarks

In case of emergency whom to contact (Local Guardian):

Mobile no:

Mr./Mrs.
Checked & Verified with Signature:

Admission department: ..........................................................

Date: .................................................

Details of Institution last attended:

Name of the Institution .....................................................................................................................................................................

Board/University ..............................................................................................................................................................................
Academic session in which admitted ................................................ Course of study ...............................................................................
Declaration by the candidate

I do hereby declare:
1)
2)
3)
4)
5)
6)
7)
8)

that the information given above are true to the best of my knowledge and belief,
that my admission will be liable to stand cancelled if any of the aforesaid information is found to be untrue,
that I shall scrupulously abide by the standing rules of the Institute,
that I shall be liable to face punishment, including expulsion from the Institute, for any offence committed on my part in
violation of the rules of the Institute,
that I shall do everything in my power to enhance the reputation and honour of the Institute,
that I shall not commit any act that would bring disrepute to the Institute and shall not be involved in any activities that
would tarnish the image of the Institute,
that I am fully aware of the Act regarding participation in ragging and of the punishment that may be meted out to me if I am
found guilty of ragging and that I am liable to be punished in terms of the said Act, and
that my admission shall be treated as provisional till production of my mark sheet for the 10+2/UG Examination.

Date: ................................................

I do hereby declare:

Signature of the candidate ....................................................

DECLARATION BY THE PARENT(S) / GUARDIAN

1) that the information given by the candidate are true to the best of my knowledge and belief,
2) that I shall be responsible for payment of Institute dues at the prescribed rates on a regular basis,
3) that I agree to cooperate with the Institute authority in adopting corrective measures in case the candidate does not abide by the rules of the
Institute and becomes liable to be punished on being found guilty of violating the rules, and
4) that I am fully aware of the Act regarding participation in ragging and of the punishment that may be meted out to my ward in terms of the said Act
if he/she found guilty of ragging at any time during his/her studentship in this Institute.
Signature of the Parent/Guardian .....................................................................................
Name in full (in BLOCK LETTER) .....................................................................................
Relationship with Candidate ............................................................................................

DECLARATION BY THE CANDIDATE

To
The Dean (Academic)
Indian Institute of Engineering Science & Technology, Shibpur
Howrah-711103

Affix
Stamp size
colour photograph

Sir,
I have gone through the Code of conduct for Students of this Institute and shall abide by it in course of my study at this Institute.
1. I shall carry Identity Card at all times within the Institute Premises.
2. I will refrain from using foul word / vulgar expression, obscene gesture to anybody.
3. I shall not indulge in any kind of hooliganism, bursting of firecrackers, causing any kind of noise pollution /physical / mental abuse to
anybody inside the campus.
4. I shall not smoke in any of the Institute building as per judgement of the Honble Supreme Court.
5. I shall not use alcohol, drugs, narcotics of any form and display and view any obscene graphics / photographs/videographs within the
Institute premises.
6. I shall not enter into Oval or Lords ground after dusk.
7. I shall not stay outside Hostel/Hall after 10.30p.m. Without prior permission from respective superintendent. Neither I would possess any
extra keys of the hostel gate.
8. a.(For Male Students)- I shall not enter a girls hostel at any point of time.
b.(For Female Students)- I shall not enter a boys hostel at any point of time.
9. I shall refrain myself from swimming and bathing in the river Hooghly and Ponds/Jheels inside and around the campus.
10. I must attend classes regularly as per routine so as maintain attendance above 75% in each the Theoretical and Sessional subjects, as
otherwise I may not be permitted to appear for Institute and Semester Examinations.
11. I shall not keep any bike/schooter in the hostel.
12. I shall not involve myself in the act of ragging.
13. I shall not use mike/sound system with loudspeaker inside the campus.
Date: .................................
..............................................................................
Counter signed by the Guardian with date

Signature of the student ..................................................................

Name of the student .........................................................................
Department ...................................................... Year .......................

To be filled in by the Office

Certified that the particulars given by

the candidate have been verified with
.............................................................
Signature of the verifying official

Admit * .........................................................
Signature of the competent authority