NITR/AC/101

NATIONAL INSTITUTE OF TECHNOLOGY ROURKELA

Application Form for Enrolment in B.Tech. Programme

Application No 1AT210968

Admission Category JoSAA

Studentship Category B.Tech. JEEMain/ JoSAA

Department Applied
Preference Department/ Specialization cOE
1 Civil Engineering
Personal Information:

OP
Applicant Name S U R A J MOHANTY
category
NA
Date of Birth 14 Dec 2002
Disability Name/ Percentage
Blood Group O+ve Mother Tounge / Religion ODISHA Hindu

Male UnMarried
State of Residence Odisha Gender/ MaritalStatus
Country India Husband Name NA
Email Surajmohanty101325@gmail.com Mobile No 9369076277

Parental Information
Father's Name KC MOHANTY Mother's Name KABITA MOHANTY

Guardian KABITA MOHANTY, 7507570230 Name of Financing Person KC MOHANTY

Name7 ContactNo

Fathers Occupation SERVICE IN INDIAN ARMY Mother s OCCupatiOn HOUSEWIFE

Parents Annual income 700000 Relationship with Financing Person Father
Address 507 ARMY BASE WKSP. KANKINARA,WB Mobile N 8329750971

Communication Address- Fermanent Address-

Address Line1
FACTORY
CHORD LINE.EXCIDE BATTERY Address Line VILL-BAUNSHA MUKHAPO-BASTA
Address Line2 DIST-BALASORE ODISHA
Address Line2 NEAR GOLGHARBHATPARA WB Country India
Country India State Odisha
State West Bengal
PIN COde 756029
PIN Code 743125 Phone Number 8329750971
Phone Number 9369076277

Entrance Exam Details

Examination Namne 210310336/595

JEE MAIN Roll/ Registration No
Registered Email ID
Result Qualitied Surajmohanty101325@gmail.com
EXamYear 2021 Score 97.35
Subject :PHYSIcS,CHEMISTRYMATHS Rank/Percentile 25056

Academic Career

Marks(%)/
#Examination Programme Branch/Trade / Specialization School/ College Board/University YOP
CGPA
Division
10th 10th ScIENCE,MATHS,SSTENG,HIN APS PUNE,411001 CBSE 2018 443 1st

2 112th/Diploma T2th PCM ENG,CS APS NERRU ROAD LUCKNOW CBSE | 2020 482 1st
Application Fee Details:

Application Fee is Not Applicable for Selected Studentship Category

Declaration by Applicant:

I do hereby declare that the information furnished in this application

is true to the best of my knowledge and belief and if admitted I shall
abide by the rules and regulations of the Institute and Halls
attached to it. If any information furnished in this application is
found to be false, I am liable to forfeit the seat allotted to me and
legal action may be taken against me.

I agree to stay in Hall of Residence and room allotted to me by the

authorities and shall abide by the rules of the Hall.

I shall not participate in any move to create group / class feeling

amongst the various students. I am aware of the rules regarding
ragging / harassment of juniors as well as the punishments thereof.
I undertake that if found guilty of the above I will be liable for
punishment as deemed fit by the authorities. I also understand that
I shall cooperate with the authorities in curbing ragging (including
reporting incidents of ragging to authorities), failing which
disciplinary action as per rules will be taken against me.