HARCOURT BUTLER TECHNICAL UNIVERSITY KANPUR

(Examination Form For Carry Over students)

This application must be submitted to Academic Office

Studying in
Roll No. Branch Semester Mobile No.
Year

To,

Hon'ble Vice Chancellor

Harcourt Butler Technical University, Kanpur

Sir,
Kindly grant me permission to appear in the ensuing I/II/III/IV year Semester Final Examination for Bachelor of
Technology/Master of Technology/Master of Computer Applications/Ph.D.
I declare that :
1. I have read the rules, relevant ordinances, statutes etc., and undertake to abide by them. I will not claim any benefit arising out of some
error or mistake on the part of the University Office.
2. I am not appearing for any other examination of the University not permitted under the Ordinance.
3. I have not been debarred from appearing in the examination by any University on account of use of unfair means.
4. I will have no objection if I am being searched by any one deputed by the Superitendent of the Examination during course of
examination.

(Signature of Candidate)

PARTICULAR TO BE FILLER BY THE STUDENT

1. Name of the Course: 2. Session: Affix a good quality

latest coloured
photograph
3. Semester: 4. Branch Code:

5. Status of Students : Regular Readmitted Ex- Student Carry Over

6. Name of candidate in capital letter (records as per High School, In English)

Nk= dk uke ¼Nk= dh 10oha d{kk ds vfHkys[k ds vuqlkj] fgUnh esa½

7. Father's Name (as per High School records, in English)

firk dk uke ¼Nk= dh 10oha d{kk ds vfHkys[k ds vuqlkj] fgUnh esa½

8. Mother's Name (as per High School records, in English)

ekrk dk uke ¼Nk= dh 10oha d{kk ds vfHkys[k ds vuqlkj] fgUnh esa½

9. Date of Birth :
10. Category : GEN OBC SC ST

11. Gender : Male Female 12. Year of Admission

13. Enrollment No.: 14. Roll No. :

15. E-Mail ID 16. Adhaar No.
17. Particulars of the Qualifying Examination passed: (Inter/Graduation/Diploma/B.Tech. I/II/III, MCA I/II, M.Tech.)
Name of Examination: ___________________________ Year: _________________Roll No.: ___________________________

18. Wheather he/she has appeared at this Examination before. If so, give details :
 Name of Examination: ________________ Year: __________ Roll No.: _____________________
Result of Examination: ______
19. Particulars of passing First, Second and Third year of the Programme

Examination If promoted with Carry Over papers

Marks Maximum
B.Tech./MCA/ Year Roll No. Result provide name of papers and whether it is
Obtanied Marks
M.Tech. cleared / not cleared

First Year

Second Year

Third Year

Final Year

20. Subject codes and Paper ID in which student wishes to appear in this Examination
Theory Subjects Practical & Other Subjects
Paper Name Paper Code Paper ID Practical Name Paper Code Paper ID

21. Complete permanent mailing address of the student

(Write in capital letters)
Name: ________________________________________________________________________________________________
Address :______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_______________________________________________________________________________Pin code : ______________
Contact No. (Presently used by student) :

DECLARATION BY THE CANDIDATE

I hereby declare that the information given above has been filled by me and is correct to the best of my knowledge and belief.

(Signature of the Student)

 HARCOURT BUTLER TECHNICAL UNIVERSITY
KANPUR
Session 2020-21
VERIFICATION CARD

Name of Course* B.Tech. / M.Tech./ MCA / Ph.D Year of the programme* I / II / III / IV
Status of student* Appearing for CO Branch*
Roll No. Enrolment No.
Name of Candidate*
(in capital letters)
Gender
Father's Name*

Subjects in which examination is undertaken :

Permitted to appear
_____________________________________________________________________
in the examination
_____________________________________________________________________

_____________________________________________________________________
Affix a good quality latest
coloured photograph
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________ Dean of Academic

Affairs Candidate's Signature

* The information furnished by student should be verified with Registration card at the time of Examination.

RECORD OF ATTENDANCE IN THE EXAMINATION HALL

Answer
Date Subject Name Subject Code Booklet Room No. Signature of student Signature of Invigilator
No.

Signature of Controller Signature of Senior Superintendent of Examination

 HARCOURT BUTLER TECHNICAL UNIVERSITY
KANPUR
Session 2020-21
ADMIT CARD

Name of Course* B.Tech. / M.Tech./ MCA / Ph.D Year of the programme* I / II / III / IV

Status of student* Appearing for CO Branch*

Roll No. Enrolment No.

Name of Candidate*
(in capital letters)
Gender

Father's Name*

Subjects in which examination is undertaken :

Permitted to appear
Subject Code Title of Subject
in the examination

Affix a good quality latest

coloured photograph

Dean of Academic
Affairs Candidate's Signature

Note : Students are advised to bring Admit Card for appearing in all the examination listed above. Entry will not be allowed without Admit Card.