Approved By AICTE New Delhi & Govt.

of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net

REGISTRATION FORM (B.E.) 2016 - 2017

Date of Registration …………………

Domicile:- M.P. / AI Category:- ( Gen / OBC / SC / ST )

Recent
passport
12th Roll No. ……………..……….… 12th %:- ……..… 12th PCM% .............
photograph

Name of Board: ……………………………….. Year of Passing- ……….…

JEE Roll No. …………………………. JEE Marks …………

1. Student Name [In Capital]:-

First Name Middle Surname

2. Father’s Name:-

3. Mother’s Name:-

4. Gender.: Male Female

5. Date of Birth: Date Month Year

6. E-mail I.D. ……………………………………………………………………………….

7. Permanent Address:- ……………………………………………………………….……

………………………………………………………………………………………...…..
……………………………………………………… Pin Code

8. Present Address:- ………………………………………………………………….……

………………………………………………………………………………………...…..
……………………………………………………… Pin Code

Candidate Mob. No.1

Guardian Mob. No.2

(Contd……)
 Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net

REGISTRATION FORM 2016

LATERAL ENTRY
Name of Institute: _________________________________________
Affix
Course: B.E. / B. Pharm recent
Branch:- ( EC / CS / IT / ME / EX / Civil) Photo

Domicile:- M.P. / AI Category:- ( Gen / OBC / SC / ST )

Diploma/B.Sc. Roll No.:………………… Diploma/B.Sc. Marks ……………
Diploma/B.Sc.: Theory % , ……………… Aggregate %………………
1. Student Name [In Capital]:-
First Name Middle Surname

2. Father’s Name:-

3. Mother’s Name:-

4. Gender.: Male Female

5. Date of Birth: Date Month Year

6. E-mail I.D. ……………………………………………………………………………

7. Permanent Address:- ……………………………………………………………….

………………………………………………………………………………………..
……………………………………………………… Pin Code

8. Present Address:- ……………………………………………………………………

………………………………………………………………………………………...
……………………………………………………… Pin Code

Candidate Mob. No.1

Guardian Mob. No.2

(Contd……)
 Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net

REGISTRATION FORM (MCA) 2016 - 2017

Date: ………………………..

Name of the Institute (to which registered): …………………………………

Recent
Domicile:- M.P. / AI Category:- ( Gen / OBC / SC / ST ) passport
photograph
Maths at 12th Graduation

Graduation in : ………….……….. % ……..…… Year of Passing- …………

Pre-MCA Roll No. ……………………. Pre-MCA Marks …………………..

1. Student Name [In Capital]:-

First Name Middle Surname

2. Father’s Name:-

3. Mother’s Name:-

4. Gender.: Male Female

5. Date of Birth: Date Month Year

6. E-mail I.D. ……………………………………………………………………………….

7. Permanent Address:- ……………………………………………………………….……

………………………………………………………………………………………...…..
……………………………………………………… Pin Code

8. Present Address:- ………………………………………………………………….……

………………………………………………………………………………………...…..
……………………………………………………… Pin Code

Candidate Mob. No.1

Guardian Mob. No.2

(Contd……)
 Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net

REGISTRATION FORM (MBA) 2016 - 2017

Date of Registration …………….………
Name of the Institute (to which registered): ………………………………… Recent
passport
Domicile:- MP / AI Category:- ( Gen / OBC / SC / ST ) photograph

CMET Roll No.:-……………………… CMET Marks: ………….…………..

SN. Name of Course/ Name of Institute Board/ Univ. Year of % Enroll. No.
Examination Stream Passing
1 10th
2 12th
3 UG
4 PG
1. Student Name [In Capital]:-
First Name Middle Surname

2. Father’s Name:-

3. Mother’s Name:-

4. Gender.: Male Female

5. Date of Birth: Date Month Year

6. E-mail I.D. ……………………………………………………………………………….

7. Permanent Address:- ……………………………………………………………….……

………………………………………………………………………………………...…..
……………………………………………………… Pin Code
8. Present Address:- ………………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
Candidate Mob. No.1
Guardian Mob. No.2
(Contd……)
 Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net

REGISTRATION FORM SESSION 2016-2017

M.E. / M.Tech
Recent Passport
Photo with Sign.
Name of the Deptt. Branch

First Name Middle Name Surname

1. Name
(Block letters)
2. Father’s Name ______________________________________________________________
3. Mother’s Name ______________________________________________________________
4. Gate/Non Gate/Sponsored __________________________ 5. Gate Percentile __________________
6. Name of Qualifying Examination (BE/B.Tech/MCA) ____________________%________________
7. Category (Gen/SC/ST/OBC/Disabled) ________________ 8. Sex (Female/Male) _______________
9. Date of Birth __________________________ 10. Nationality _______________________
11. Religion: …………………..…... 12. Caste: ……………………………………………...

13. Whether Belongs to Economical Backward Class: Yes No

(If yes, enclose it’s support)
14. Permanent Address:- ………………………………………………………………………….……
.………………………………………………………… Pin Code
15. Present Address:- ………………………………………………………………………….……
.………………………………………………………… Pin Code

Candidate Mob. No.1

Guardian Mob. No.2

16. Qualification (Starting from 10+2 till date):-

SN. Name of Subject / Board/Name of the Year of Percentage of Remarks Encl.
Examination Branch Institution/University Passing Marks & Division No.
1 10th
2 12th
3 BE/B.Tech/MCA

(Contd……)