NATIONAL INSTITUTE OF TECHNOLOGY PATNA

ASHOK RAJPATH, PATNA – 800 005, BIHAR

Tel/Fax No.: +91-612-2660480 (Extn-104)
Prof. S. K. Verma
Email: dy. director@nitp.ac.in
Deputy Director

Ref.: NITP/Dy.D/150/21 Date : 19.08.2021

NOTICE
Physical Reporting for Admission to M.Tech/ M.Arch./MURP Programmes through
CCMT 2021 during Aug 26 (Thu) – Aug 31 (Tue), 2021, 17.00 hours

Candidates who have got seat through CCMT 2021 process for admission to
M.Tech./M.Arch./MURP programmes at National Institute of Technology Patna for the
academic year 2021-22 (July-Dec 2021 Sem) are required to follow the following steps:

i. Following forms of NIT Patna to be submitted (Form is attached with this notice)
a. Admission Form
b. Affidavit by the student regarding anti-ragging
c. Affidavit by the parent/guardian regarding anti-ragging
d. Medical Certificate should be issued from the registered Medical
Practitioners/ Govt. Doctors
e. Affidavit with respect to Gap year (i.e. reason for discontinuity between
passing year of qualifying examination and year of admission to B. Tech/
B. Arch/ Master’s program.), if applicable
f. Undertaking on stamp paper of Rs. 100/- regarding refund of scholarship
in the case of withdrawal from M.Tech/ M.Arch /MURP program without
completing
g. Other Undertaking, if applicable
ii. GATE score card (2019/2020/2021) as applicable
iii. Four passport size photographs identical to the one uploaded during GATE
2019/2020/2021
iv. Original Conduct Certificate from the University/ Deemed University /
Institute/school last attended
 v. Original Migration certificate from the University/ Deemed University / Institute
last attended
vi. Online Document Verification Certificate (ODVC) downloaded from the CCMT
2021 portal in student’s login
vii. Provisional Seat Allotment Letter (PSAL) generated from CCMT 2021 website
during 3rd Round/2nd Special Round, as applicable
viii. Proof of seat acceptance fee paid/Remaining Fees paid to either CCMT 2021/NIT
Patna
ix. Photo identity card [issued by govt. agency/last attended school/Class XII admit
card]
x. Proof of Date of birth [Class X mark sheet/pass certificate]
xi. Class XII (or equivalent) board mark sheet and Pass certificate.
xii. Qualifying Examination (B. Tech/ B.E./ B. Sc. Engg/ B. Arch.): All Marks
Sheets/ Grade Cards and Passing Certificate.
If a candidate has cleared his/her qualifying degree exam but his/her
Institute/University have yet not issued the provisional/degree certificate/
final Mark sheet then such candidates should submit UNDERTAKING on
non-judicial stamp paper of Rs. 100 "NON AVAIBILITY OF
PROVISIONAL/DEGREE CERTIFICATE". The format is attached
herewith.
xiii. Category certificate (GEN-EWS/OBC-NCL/SC/ST), if applicable in the
prescribed format
a) Regarding GEN-EWS/OBC-NCL Certificate: EWS/OBC-NCL
category certificate must be issued on or after 01.04.2021.
b) Regarding GEN-EWS Certificate: It is to be noted that the GEN-EWS
certificate must be VALID FOR THE YEAR 2021-2022, but it must be
issued in the prescribed format for the financial year 2020-21.
xiv. Certificate for Persons with Disabilities (PwD), if applicable. The certificate will
be rejected if the disability is less than 40%.

 Bring all original documents mentioned above for Verification. Original Document
mentioned at S.No. i to v and Self-Attested copy of documents mentioned at S.No. vi
 to xiv should be submitted during the time of Physical reporting (Aug 26 (Thu) –
Aug 31 (Tue), 2021, 17.00 hrs).
NOTE:

1. If any discrepancy is found in the documents submitted during Physical Verification

for admission, then his/her admission will stand cancelled.
2. In the case of wanting documents, the admission will remain provisional and no
scholarship will be released till the admission is confirmed.
3. Classes will start from 1st September 2021 in physical mode.
4. For any query, please send mail to abhay.ar@nitp.ac.in

Dy. Director
Copy to:
1. Dean(Academic)
2. All HoDs
3. Associate Dean(Exam)
4. PI(MIS & Web Services)
5. DR(F & A)
6. Secretary to Director
7. PA to Dy. Director
8. PA to Registrar
9. Guard File
 NATIONAL INSTITUTE OF TECHNOLOGY PATNA
(An Institution of National Importance under MHRD, Govt. of India)
Ashok Rajpath, Patna – 800005 (BIHAR)
Application form for Admission to
M. Tech./ M.Arch/ MURP
Institute Roll No.
(to be assigned by Receiving office)

To be filled by the candidate in his/her own handwriting in Capital letters except signature
PHOTOGRAPH
Details of Fee Mode of Payment Amount Affix recent passport size
Paid to CCMT (Attach Proof) photograph
Paid to NIT Patna (Attach Proof)
Total And
Put your signature in box provided
GATE Exam and Year Candidate Category (Put  mark) below this space in
Blue gel Pen
Selection Exam Roll No OP/ General
Selection Exam Rank (All India) OBC-NCL
Selection Exam Score (marks) SC
Selection Exam Subject ST
Qualifying Exam/ Degree and Branch PH
Resident of State: EWS
Blood Group Admitted OP/OBC-NCL/SC/ST/OP-PwD/OBC-NCL-
under which
PwD/SC-PwD/ST-PwD/EWS-PwD/EWS/
category
Religion Caste

Admission/ Selection Details for Program: M. Tech/ MURP/M.Arch

Selection Examination Appeared (Put  mark) GATE 2019/2020/2021
Admitted through / Admission Date at NIT Patna CCMT 2021 / DD/MM/YYYY
(Should be verified by Verifying officer)
Aadhaar No. /PAN No. (Attach Proof) Aadhar No.:
PAN No.:
Final allotted Branch/ Department/ Specialization

1. Name of candidate in full

(as per 10th Certificate)

Name of candidate in Devnagari (Hindi)

2. Father’s Name
3. Mother’s Name
4. Guardian’s name in full (if father is not alive)
5. Date of Birth (dd-mm-yy)/ Sex: Male/ Female
6. Occupation of Parents Father: Mother:

Parents Income per annum from all sources

Organization where father/ Mother is
working or Guardian (if father is not alive)
7. Correspondence Address

Pin Code:
Phone No. (with STD Code)/ Mobile No.:
Email ID:
Page – 1 of 3
8. Permanent Address

Pin Code:
9. Academic Details:
Exam Branch/ Specialization Institute/ University Year of Passing
Matriculation/ 10th
Intermediate/ 12th
Bachelor’s level
10. SGPA/ CGPA/ % Marks: SGPA CGPA % Marks Overall % Marks
th
Matriculation/ 10 (Fill in applicable column)
th
Intermediate/ 12 (Fill in applicable column)
nd st
Bachelor’s Degree: 2 Sem/ 1 Yr
(Fill in applicable column) th nd
4 Sem/ 2 Yr
th rd
6 Sem/ 3 Yr
th th
8 Sem/ 4 Yr
th th
10 Sem/ 5 Yr
11. Declaration of the Candidate:
I,………………… ……………… ….…………………… Son/ Daughter of Sri………….…………………………
Declare that : -
a) Information furnished above are correct and in case any of the information is found false or forged at any stage of my
admission to and/ or stay in the Institute, I shall be liable (i) to lose my candidature for admission to the program, (ii)
for expulsion from the Institute if admitted and (iii) for appropriate legal action.
b) In the event of my being admitted to this Institution, I shall abide by all the rules and regulations of the Institute and
the University, concerned.
c) I have submitted my qualifying examination passing certificate with the application form. OR
I will submit my qualifying examination passing certificate by the due date notified by CCMT, else my admission shall
stand cancelled. (Strike out whichever is not applicable)

Place : _________________
Date : _________________ Full Signature of the Candidate in English

12. Declaration of the Father / Guardian: Candidates may submit the declaration of Father/ Guardian in their own handwriting separately even
after admission if Father/ Guardian is not available at the time of admission.

I,……………… ………………… …………… ………….. ………….(Name) declare that in the event of Sri/Smt./ Miss……………
…………………… ………….. …………..being admitted to this Institution. I shall be responsible for his / her conduct and
undertake to pay all his/ her Institute, Hostel, Mess and other dues regularly till the completion of his / her studies. I further
certify that the Information furnished by him/ her are correct.

Place :
Date : Full Signature of Father / Guardian

Page – 2 of 3
 Roll No. (to be assigned by
Name of the candidate in full Receiving office)
(Put  mark)
1. Please verify the Self attested Photocopies of following:- (as applicable)
(i) CCMT Reporting Letter and Allotment Letter
(ii) GATE Score Card (2018/2019/2020)
(iii) Certificate of Category OBC-NCL/ SC / ST, if applicable, Issued by the competent authority
(iv) Income Certificate for OBC Candidates for claim with respect to Non creamy Layer issued by
competent authority/ as per directive of the MHRD. (If seat allotted in OBC-NCL category)
(v) Certificate for Person with Disabilities/ Physically handicapped
(vi) Class X (High School) Board Certificate as proof of Date of Birth

Must be submitted at the time of Admission

(vii) Matriculation (10th)) Marks Sheet
(viii) Qualifying Examination Marks Sheet/ Grade Card: (Strike out whichever is not applicable)
Intermediate (12th ) Marks Sheet
B. Tech/ B.E./ B. Arch. Or equivalent
(ix) Qualifying Examination passing certificate (as applicable for the program). In case it is not
being submitted then undertaking for submission by due date fixed by CCMT.
(x) Affidavit with respect to Gap year (i.e. reason for discontinuity between passing year of
qualifying examination and year of admission to B. Tech/ B. Arch/ B.E.)
(xi) Four copies of Photograph. (identical to one Pasted on the application form)
(xii) Migration & or Transfer Certificate from the University/ Deemed University / Institute last
Attended
(xiii) Conduct Certificate from the University/ Deemed University / Institute/school last Attended
(xiv) Proof of Payment for Admission Fee as per Information Brochure/ program
(xv) Affidavit by the student regarding anti-ragging
(xvi) Affidavit by the parent/guardian regarding anti-ragging
(xvii) Undertaking on stamp paper of Rs. 100/- or more regarding refund of scholarship in the case
of M.Tech/MURP/M.Arch
(xviii) Medical Certificate should be issued from the registered Medical Practitioners/ Govt. Doctors
2. Signature of documents Verifying Officer(s):

1………………..….. 2………………….…….. 3………….………..

(To be obtained at the time of admission in presence of Institute representative only)
3. Full Signature of the Candidate: (English)

Left Thumb impression of the Candidate

Signature of Admission-In-Charge of the Department/

Institute

Page – 3 of 3
 AFFIDAVIT BY THE STUDENT
(On non-judicial stamp paper of Rs.100/- or more)
I…………………………………(Name of Candidate) GATE Registration ID:
………………………………….D/S/o Shri ………………….…………… Resident of ………………,
having been admitted to National Institute of Technology Patna, have received a copy of the
UGC Regulations on Curbing the Menace of Ragging in Higher Educational Institutions,
2009, (hereinafter called the “Regulations”) carefully read and fully understood the provisions
contained in the said Regulations.
2) I have, in particular, perused clause 3 of the Regulations and am aware as to what
constitutes ragging.
3) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully
aware of the penal and administrative action that is liable to be taken against me in case I
am found guilty of or abetting ragging, actively or passively, or being part of a conspiracy to
promote ragging.
4) I hereby solemnly aver and undertake that
a) I will not indulge in any behavior or act that may be constituted as ragging under
clause 3 of the Regulations.
b) I will not participate in or abet or propagate through any act of commission or
omission that may be constituted as ragging under clause 3 of the Regulations.
5) I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause
9.1 of the Regulations, without prejudice to any other criminal action that may be taken
against me under any penal law or any law for the time being in force.
6) I hereby declare that I have not been expelled or debarred from admission in any institution
in the country on account of being found guilty of, abetting or being part of a conspiracy to
promote, ragging; and further affirm that, in case the declaration is found to be untrue, I am
aware that my admission is liable to be cancelled.
Declared this ___day of __________ month of ______year.
_________________________
Signature of deponent
Name: __________ __________ ___________
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of the
affidavit is false and nothing has been concealed or misstated therein.
Verified at ____________ (place) on this the _____ (day) of_______ (month) , _________ (year ) .

________________ Signature of deponent

Solemnly affirmed and signed in my presence on this the (day) of (month), (year) after reading the
contents of this affidavit.

OATH COMMISSIONER

1 of 2
 AFFIDAVIT BY PARENT/GUARDIAN
(On non-judicial stamp paper of Rs.100/- or more)

I, Mr./Mrs./Ms. _________________ __________________ __________________ (full name of

parent/guardian) father/ mother/ guardian of , __________ ________ _______ _______ ____ (full name of
student), GATE Registration ID: …………………………………., having been admitted to National
Institute of Technology Patna, have received a copy of the UGC Regulations on Curbing the
Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the
“Regulations”), carefully read and fully understood the provisions contained in the said Regulations.
2) I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes
ragging.
3) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully
aware of the penal and administrative action that is liable to be taken against my ward in case
he/she is found guilty of or abetting ragging, actively or passively, or being part of a conspiracy
to promote ragging.
4) I hereby solemnly aver and undertake that
a) My ward will not indulge in any behaviour or act that may be constituted as ragging
under clause 3 of the Regulations.
b) My ward will not participate in or abet or propagate through any act of commission or
omission that may be constituted as ragging under clause 3 of the Regulations.
5) I hereby affirm that, if found guilty of ragging, my ward is liable for punishment according to
clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken
against my ward under any penal law or any law for the time being in force.
6) I hereby declare that my ward has not been expelled or debarred from admission in any
institution in the country on account of being found guilty of, abetting or being part of a
conspiracy to promote, ragging; and further affirm that, in case the declaration is found to be
untrue, the admission of my ward is liable to be cancelled.
Declared this ____ day of __________ month of _______ year.
_____________________
Signature of deponent
Name: __________________________________________
Address:_________________________________________
Telephone/ Mobile No.: ____________________________
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of the
affidavit is false and nothing has been concealed or misstated therein.
Verified at __________ (place) on this the ___ (day) of _________ (month) , __________ (year ) .
____________ ________________
Signature of deponent
Solemnly affirmed and signed in my presence on this the ___ (day) of ________ (month) __________
(year ) after reading the contents of this affidavit.

OATH COMMISSIONER

2 of 2
To
The Notary Public
--------------------------

Affidavit for Gap Year

I _______________________________________________________________

S/O _____________________________________________________________

Resident of ____________________________ P.O. ______________________

P.S. ____________________________District __________________________

do hereby solemnly declare and affirm as follows:-

1. That I have passed the qualifying examination ______ ______ ____ _____
from _____ _____ _____ ______ ______ ______ _____ _____ in the year
_____ ______

2. That after passing the aforesaid examination I have not taken admission in
any college/ school/ institution during the period from _______________
___________________ till this date.

3. That after passing of the qualifying examination, I was not involved in any
criminal offence during the period from ______ _____ _____ till this date.

4. That from _____________________ the date of reporting/ admission to

___________________ the date of reporting for attending classes, I was sick
and was under treatment of Dr. ____________________ ________________
That the contents of this affidavit are true and correct to the best of my
knowledge and belief.1

Signature of the candidate/ Deponent

I identify the deponent who signed in my presence.

1
Delete/ Strike out if not applicable
 NATIONAL INSTITUTE OF TECHNOLOGY PATNA
(An Institute under Ministry of HRD, Govt. of India)
ASHOK RAJPATH, PATNA-800 005 (BIHAR)
…………………………………………………………………………………….………………………………………………………………………………
MEDICAL EXAMINATION FOR PHYSICAL FITNESS
(To be obtained from any Registered Medical Practitioner)

Name: ………............................................................. S/O........................................................................................

I. General Examination: …………….. ……… Height …………cms. Weight ………....Kgs.

II. C.V.S. : Pulse: ……………/ Minute; Regular / Irregular B.P.: …………………………..

III. Respiratory System: ……………………………………………………………………………………..

IV. GI System: ………………………………………………………………………………………………

V. Musculoskeletal System : Normal / Disabled (If disabled refer to a specialist)

VI. Skin: ………………………………………………………………………………………………….….

VII. Examination of Eyes: Normal / Defective: ……………………… Spectacles………………………….

(If any abnormality is found, refer to the specialist)

VIII. E.N.T.: Normal / Abnormal: …………………………………..

(If any abnormality is found, refer to the specialist)

IX. C.N.S.: ………………………………………………………………………….……………………….

X. G.U.S.: …………………………………………………………………………………………………..

XI. Female Candidate: Menstrual History: ………………………………………………………………….

XII. Blood Group & Rh: ……………………………………………………………………………………..

I do hereby certify that I have examined the above candidate for admission to ……………………….. Programme
in National Institute of Technology Patna, ………………………… department and cannot discover that he / she
has any disease and constitutional defect or bodily infirmity except that
……………………………………………… I do not consider this as a disqualification for undergoing the above
programme. His / Her age according to his/her own statement is ………………………. years and by appearance
……………. years.

Personal Marks of Identification:

1…………………………………………………………….……..

2……………………………………………………………………

Date:

Place: Signature of Doctor

(With seal & Regd.No.)

(* Any defect to be noted in Detail)_____________________________________________________________

__________________________________________________________________________________________
 NATIONAL INSTITUTE OF TECHNOLOGY PATNA
(An Institute under Ministry of HRD, Govt. of India, New Delhi)
ASHOK RAJPATH, PATNA-800 005 (BIHAR)
………………………………………………………………………………………………………………………………………………………........................
CERTIFICATE OF PHYSICAL FITNESS
(Declaration by the candidate for the issue of Physical Fitness Certificate)

Name: …………………………………………………………… Male/Female Branch: …………………………

Date of Birth: Age (in years):

Address: ………………………………………………………………………………………………………………

………………………………………………………………………………………………………………..

Indicate your response by Y/N (Y means Yes; N means No)

Do you have any minor or major complaint?

If yes, describe …………………………………………………………………………

Are you allergic to any medicine or any others?

If yes, describe …………………………………………………………………………

Have you ever been affected with?

Small Pox, Chicken Pox Asthma

Intermittent or any fever Epilepsy

Enlargement or suppuration of glands Appendicitis

Spitting of Blood Lungs Disease

Heart Disease Rheumatism

Fainting Attacks Any Other ……………………

Have you ever had any operation or been advised any operation?

If yes, describe …………………………………………………………………………………………..

Are you handicapped? Visual / Hearing / Orthopedic

Immunization had: BCG OPV DPT M.M.R. ……………

Preventive vaccination (Please tick):

Chicken Pox Typhoid Hepatitis-B
Rubella (F) Any other (specify)…………………………

Blood Group & Rh ………………………………………………………………………………………………….

Personal Marks of Identification: 1...……………………………………………………………………………….

2. …………………………………………………………………………………

I declare that all the above information are true and to the best of my knowledge.

Signature of the Candidate

 UNDERTAKING
(On non-judicial stamp paper of Rs. 100/-)

I……………………………… son/daughter of …………………………………………..,

resident of …………………………………………………………….., hereby declare that I

will refund the amount received by me from the institute as Scholarship/ Stipend, in case I

withdraw from/leave the institute before completing the requisite criteria for award of my

M.Tech./MURP/ M.Arch Degree as per academic regulation of the Institute.

Signature of the Candidate Signature of the Parent/ Guardian

 AFFIDAVIT BY THE STUDENT
(On non-judicial stamp paper of Rs.100/- or more)

Non Avaibility of Provisional/Degree Certificate/Final Mark sheet

I…………………………………(Name of Candidate) GATE Registration ID:

………………………………….D/S/o Shri ………………….…………… Resident of
……………… do hereby solemnly affirm and state as follows:

1. That I am a bonafide student of ………………………………Course/Programme in

Institute/University…………………………..………with Enrollment no…………………….

2. That I have completed all the requirements of the course/programme for the award of degree
and do not have any backlogs. But due to COVID-19 Pandemic, the provisional/degree
certificate/Final Mark sheet has not been issued by the Institute/University.

3. I undertake that I will submit my degree/provisional certificate/ Final Mark sheet issued by
the Institute/University latest by 08.10.2021 to NIT Patna, failing which I understand that my
admission in M.Tech./M.Arch./MURP Programme may be cancelled.

4. That I further understand that if I am unable to qualify the minimum eligibility criterion for
admission to M.Tech./M.Arch./MURP Programme, my admission will stand cancelled and
the admitting Institution shall have no liability for the same.