Bhivarabai Sawant Institute of Technology & Research (W ... - JSPM

JSPM’s
Bhivarabai Sawant Institute of Technology & Research (W),
Wagholi, Pune
APPLICATION FOR M.E ADMISSION
Academic Year 2012-13
M.E. Electronics (VLSI & Embedded System) -
M.E Computer -
1. Name in Full (in BLOCK LETTERS) :
2. Postal Address for Correspondence :
3. Permanent Address :
Application form along with Enclosures – ‘A’ and ‘B’ be filled in by the candidate and must be submitted
to the following address:-
The Principal,
Bhiwarabai Sawant Institute of Technology & Research (W).
Gat No. 720 / (1, 2), Pune – Nagar Road., Wagholi
Pune – 412207. (Maharashtra)
Paste Self attested
photo
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4. Telephone No. / Mobile No. :
5. E-mail Address :
6. Domicile :
7. Nationality :
8. Date of Birth (DD / MM/ YYYY) :
9. Reserved Category (SC /ST/OBC/NT/VJ) : Caste :
10. Religion :
11. Father / Guardian Full Name :
12. Father / Guardian Occupation :
13. Annual Income (In Rs.) :
14. (a) Academic Record :
Course &
Examination
College
Attended
Month &
Year of
Passing
No. of
Attempts
1 st Year
Engineering
2 nd Year
Engineering
3 rd Year
Engineering
4 th Year
Engineering
Any other
Course
Qualified GATE Score, Valid FOR AY 2012 : YES / NO
University
/ Board
If YES, specify the GATE Score :
(b) Work Experience: (attach extra sheet, if space is not enough)
Name of the Organization / Industry
Total
Marks
Obtained
Marks
(Out of)
Period Post
%
Marks
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15. Employed or Unemployed? : Yes / No
If employed give details (e.g. Date of Appointment,
Regular / Temporary, Length of service etc.) :
16. Sponsorship certificate attached? : Yes/ No
[Note-Employed candidates will have to produce a certificate from the employer in the
prescribed Performa, without which the application may not be considered.]
17. I the understand declare that the admission given against the quota for reserved category
belonging to BC/SC/ST is purely provisional and will be cancelled if my caste certificate is rejected
by the Director of Social Welfare, Maharashtra State.
Date:
Place: (Signature of Candidate)
18. Declaration by the Father/Guardian of the applicant
I do hereby, declare that-
(i) The particulars furnished by my daughter/ward in this application form are Correct to the best of
my knowledge.
(ii) I undertake and bind myself to pay on behalf of my daughter/ward fees charges of the college and
I also agree the terms and conditions as well as rules and regulations laid down by the college
authority. In case of failure of my ward, Principal of the college may take proper action
against my daughter/ward.
Date: Signature:
Place: Name of Father/Guardian:
Application fee Details:
(For Office Use)
(Application Fee of Rs.500/- has been paid by D.D drawn in favor of Principal, Bhivarabai Sawant
Institute of Technology & Research (W), Wagholi, payable at Pune .) by
D.D.No.: Of Bank: Dated:
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UNDERTAKING
Enclosure - A
All the candidates for admission to post graduate courses in engineering/technology are required to give
following undertaking and submit with application form.
A. I have read all the rules of admission for the current year and after understanding those rules, I
have filled in this form of application for admission for the current year.
B. I have not been debarred from appearing at any examination held by any government constituted
or statutory examination authority in India.
C. I fully understand that the offer of course or branch of engineering will be made to me depending
on merit and availability of seat at the time of scrutiny of my application will report to admission
authority according to schedule of admission.
D. I understand that no other document, other than those attached to application form before the last
date of admission authority according to schedule of admission.
E. I hereby agree to conform to any rules, acts and laws enforced by government and institution and
I hereby undertake that so long as I am a student of college, I will do nothing either inside or
outside the college which may result in disciplinary action against me under the rules, acts and
laws. I will not get involved in ragging or antisocial activity of any kind.
F. I understand that my admission is provisional, subject to fulfilling of eligibility criteria of Pune
University and may be cancelled by principal for technical governance and discipline.
G. I fully understand that principal of college where I would be admitted, will have right / rusticate
me from the college for any infringement of rules of conduct and discipline as prescribed by
BSIOTR(W),Pune /Pune University.
H. The information given by me in my application is true to best of my knowledge and belief.
Name of candidate:
Signature:
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CERTIFICATE
(To be issued by the employer on letterhead)
Enclosure-B
This is to certify that Smt. is
Working in this Organization / Institute as
and she is being sponsored to seek admission to M.E. Degree course at JSPM’S Bhivarabai Sawant
Institute of Technology & Research (W), Wagholi ,Pune - 412207. If she admitted to the said course,
the working hours will be permitted to attend the college as a full time student during the working hours
of the college till the completion of her course. Further it is certified that candidate will not be withdrawn
till the completion of course.
Date:
Place:
(Signature & Designation of sponsoring authority)
Sponsor Seal
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