CENTRAL INSTITUTE OF PLASTICS ENGINEERING & TECHNOLOGY

B-25 CNI COMPLEX, PATIA, BHUBANESWAR – 751 024

Self-attested
Photo
APPLICATION FORM FOR M.Sc./M.Sc. (Tech)/M.Tech (PE)/M.Tech
(PNT)
ACADEMIC SESSION – 2016-17

1. Name (in CAPITAL LETTERS) :

(as given in School Record)

2. Course Applied for : M. Sc. (Tech.) (Material Science & Engineering)

(Strike out whichever is not applicable) ) M. Sc. (Polymer Science)
M. Tech. (Plastics Engineering)
M.Tech. (Polymer Nanotechnology)

3. Gender :

4. Category(Gen/OBC/SC/ST/PH) :
(Strike out whichever is not applicable)

5. Date of Birth :

6. Nationality :

7. Complete Postal address :

(in BLOCK LETTERS using Pen)

Name : …………………………………………………………………………………………………………….

C/o : …………………………………………………………………………………………………………….

Address :……………………………………………………………………………………………………………..
…………………………………………………………………………………………………………….

City :…………………………………………………….State :…………………………………………….

STD Code :……………………………………………………Pin Code: ……………………………………..

Phone No. :…………………………………………………..Mobile No:……………………………………..

E-mail : ………………………………………………..
Entry Qualification : (Enclose self-attested certificate)

Qualification Board Year of % of marks

CBSE/ICSE/Matriculation/ passing obtained in the
State Board/Others qualifying exam

8. Occupation of Father / Guardian :

9. Annual Parental Income :

1. Up to Rs. 6,00,000/-
2. Rs. 6,00,001 and above

10. Mobile Number of the candidate :

11. E-mail ID of the Candidate :

12. Option of JEE centre : Bhubaneswar/Kochi/ Haldia/Raipur/Balasore/Hajipur/Lucknow

(Strike out whichever is not applicable)

13. Father’s / Guardian’s Name :

14. Mobile Number of the Parents:

15. E-mail ID of the Parents :

16. Details of Demand Draft No. ________________________ dated__________

(Rs. 250/- for General /OBC and Rs. 50/- for SC/ST candidates)

DECLARATION
I hereby declare that all the particulars stated in this application form are true, complete and
correct to the best of my knowledge and belief. I hereby declare that I have read and
understood the Admission regulations and instructions for filling up the application form and
shall abide by it. In the event of any information furnished above is false, my admission is liable
to be cancelled.

Date :
Place:

Signature of the Parent / Guardian Signature of the Applicant