ROORKEE INSTITUTE OF TECHNOLOGY, ROORKEE

APPLICATION FOR REGISTRATION

S.No…………

1. Name……………………………………………………………………………......

2. Father's Name……………………………………………………………………..

3. Date of Birth…………………………..Category GL OBC SC ST

4. Correspondence Address …………………………………………………………..

………………………………………………………………………………………..

5. Contact Phone Number …………….…………® …….……………………. (M)

6. Father's Occupation:Business Service Self Employed

7. Father's Annual Income Range: 0-1 Lacs. 1-2 Lacs. Above 2 Lacs.

8. Course Applied : B.Tech Ist year B.Tech IInd year MBA MCA

Branches : CSE ECE EEE IT ME

9. Academic Record : (Please attach copies of Certificate/Marks Sheet)

High School: Year Marks%

Intermediate: Year Marks% PCM% Maths%

B.A/B.Sc./B.Com: year %

Poly. Diploma: Year Marks % B.Tech Year Marks %

M.A/M.Sc./M.Tech: Year Marks %

10. Competition Rank ( Please attach copy of score card )

AIEEE Roll No. All India Rank Uttarakhand Rank

UTUEE Roll No. Rank Course B.Tech (2nd year)/MCA

MAT Score : Month of Exam Score

CAT Score : Month of Exam Score

11. Details of DD for Rs. 500/- DD No………………….. Date………………Drawn on …. ..

………………… favoring 'Roorkee Institute of Technology', Payable at Roorkee.

12. Hostel Requirement : Yes No

13. References :

1. Name & Address……………………...………………………..…Phone No. ………..….

2. Name & Address……...…………………………………….……Phone No. …………...

Signature of the Candidate