Paste (DO NOT STAPLE) a recent

colour photograph of size 3cm × 4 cm

DRIEMS (AUTONOMOUS)TANGI, CUTTACK.

ADMISSION FORM (Details to be filled by the candidate in Block Letters)

1. Name of the Student:…………………………………………………………...

2. Applied for admission to B.Tech / M.Tech, Branch ………………………

3. Gender: Male/Female 4. Date of Birth: ……………………

5. Nationality:…………………6. Religion:……………………........

7. Mother Tongue:……………… 8.Contact No. 1: ……………..... , ContactNo.2:…………………..9. Reservation: (Put tick √ mark)

10. Email ID: …………………………………………………………………11. Whether wish to stay in the college Hostel: (Put tick √ mark)

12. Details of Entrance Examination

Name of Entrance: ……………………….. Rank/ Score:…………………………….

13. Details of Academic CareerSl. No. Name of the

ExaminationSchool/College Board/

UniversityYear of Passing

%of Marks Medium of Study

1. 10th

2. +2/Diploma

3.

11. Languages and skills known place tick √ mark.Language Known Read Write Speak

12. Details of Parent/Legal Guardian:Sl.No. Contetnt Father/ Legal Guardian Mother/ Legal Guardian Local Guardian

1. Name

2. Occupation

3. Annual Income

4. Mobile No.(IMP)

5. Email Id:(IMP)

13. Address for Correspondence:PRESENT ADDRESS PERMANENT ADDRESS

Contact No. PIN: Contact No. PIN:

General SC ST OBC PH

YES NO

14. List of Documents Enclosed (Please Write YES or NO)1. HSC/10th Certificate 6. Migration Certificate2. HSC/10th Mark Sheet 8. 9. 7. Caste Certificate (SC/ST/OBC)3. +2 /Diploma Certificate 8. Resident/ Nativity Certificate4. +2 /Diploma Mark sheet 9.Income Certificate5. CLC &TC 10. Adhaar Card (mandatory)

11.10 self address stamped envelope

DECLARATION BY THE CANDIDIATEI hereby undertake that:

1. I shall be regular, punctual and sincere in attending all the classes. If my attendance falls short of 75% in any subject (65% in Medical ground with a valid medical certificate), fine will be imposed on failure in fulfillment of requisite no. of attendance in theory & laboratory, if it falls below the purview of compensation with the extra classes.

2. Otherwise I will be debarred from appearing the University Examinations/Internal Examinations in that subject as per university Regulation.

3. I will be penalized if I remain absent from the college on last working day before vacation and on the opening day after vacation.

4. I will be penalized as per the decision of the Academic Committee / BPUT Guide lines, if I found to be involved in MASS BUNK and if I fail to submit the sessional records on time and unable to appear the Internal Examination on time.

5. I will show due regards to all the teachers and staff of the Institute and senior students. 6. I shall not be involved in ragging in any form. Moreover I will report to the concerned authority

immediately if I come across any case of harassment or ragging caused to others by any student.7. I will develop a friendly relationship with the fellow students. 8. I will maintain the decorum of the Institute (Dress, Appearance, Discipline and Attitude) in the class

room, in the Examination halls, Hostel and inside the campus. .9. I will not adopt any unfair means during the time of Examinations. (Both in internal & University).10. I will not damage or steal any property of the college, hostels, fellow students and staff. 11. I will not involve in smoking, chewing of tobacco, consumption or distribution of alcoholic drinks or any

kind of Hallucinogenic drugs inside or outside the college and hostel premises. 12. I will not organize, instigate or participate in any illegal group activity except purely academic programs

either inside or outside the campus without prior valid permission of the Dean/HOD/ Principal/Director.13. The authority will not be held responsible for any unexpected incident (involving self) outside the

campus in case of unauthorized absence from the college.14. I will not have any unauthorized possession of library books.15. I will not have any unauthorized possession of weapons in any form.16. I will intimate about my absence/temporary absence to the Proctor/HOD/ Warden /superintendent of the

Hostel. Failing which college authority will not be held responsible for my own negligence/absence. 17. I will pay my college fees & hostel dues (if any) on time. College dues fixed as year Tuition fee Other fee, if any Transport Hostel accommodation feeFood

1st year

2nd year

3rd year

4th year

N.B-i. financial transaction should be through DD/RTGS/NEFT only with a valid proof of account section. ii. Cash payment in any form is strictly prohibited. Cash in any form is the sole responsibility of either Candidate or parents or legal guardians.

iii. I know apart from the above some optional fees will be charged extra to add some value added /career advancement & PPT courses, which will be helpful towards support of my placement drive. I will definitely join the programme organized by Institution directly or indirectly, which will be helpful for my career growth. Failing which I don’t have claim on institution regarding my placement assistance.iv. I know college is providing …………..% incentive, if I will clear my full dues before 15 th July of each session.v. I know in case of default in payment of dues, bank interest will be charged @personal bank loan interest. vi. For further default in payment action will be taken by the Committee / Authority / Management as deemed fit.vii. I know-------------------- Scholarship will be awarded to the meritorious students i.e. per year / for 1st

year.viii. In my case it has been finalized at Rs ------------------- (Rupees …………………………………………………) only / per year / for 1st year, as per my 10th & +2 mark or qualifying exam conducted by the institution.(mark TICK whichever is applicable)

18. University semester registration fee will be charged extra. 19. I will not create ill feelings amongst students based on State, Locality, Caste, Sex and seniority-

Juniority. 20. The institution is not responsible for any kind of life threatening attempt (suicide) by the student.21. Ignorance of rules & regulations would not be treated as matter of excuse.22. Any dispute regarding law can be settled in the jurisdiction of Cuttack District only.

I do undertake that if I will not obey the above rules and regulations of the college, I may be liable to punishment such as debarment from the student activities and receiving medals / prizes / scholarships / certificates, campus placement, forfeit of the caution money, expulsion from the hostel and college either temporarily or permanently, debarment from the internal / sessional examination, imposition of fine without any information to the Parents / Legal / Local Guardian, according to the severity of the offence. I or my Parents / Legal Guardian will not go to court of law due to our own fault /negligence.

Counter Signature of the Parents / Legal Guardian Full Signature of the Student with date

Signature of the Promotional Staff (if any) : ___________________________ Date:-

FOR OFFICE USE ONLYAdmission No.: Course: Branch: Regular/ Lateral Entry: Year of Admission: Roll No. : JEE RANK No. REGD. NO: Date of Verification:

Signature of the Admission-In charge Signature of the Principal/Director (Admin)