Application form for VITEEE - 2015

Full Name

: SOUMYA ROY CHOUDHURY

Application. No. : 2015016070

Date of Birth

: 16/04/1997

Gender

: MALE

Religion

: Hinduism

Nationality

: Indian

Community

: General/OC

Mother Tongue

: Bengali

Native State

: Assam

Mode of Study

: Regular

Landline No.

: -

Mobile No.

: 9864853488

Parent name

: DULAL ROY CHOUDHURY

Hostel

: Yes

Choice of Campus

: Vellore

Email ID.

: ultimatesoumya4@gmail.com

Qualifying Exam

: 12th Class

Month & Year Passing

: Mar - 2015

Exam Roll.No./Reg.No.

Testcity

: GUWAHATI

Permanent Address

: 22, NAYAN NAGAR,GUWAHATI,KAMRUP,ASSAM,781026.

Name of the School

: MARIAS PUBLIC SCHOOL

Address of the School

: BIRKUCHI, GUWAHATI, KAMRUP,ASSAM, 781026.

DECLARATION
I solemnly and sincerely affirm that I am an Indian National and that all particulars
furnished by me in this application form are true and correct . I have not concealed any
information. However, in the event of any information being found to be incorrect,
fraudulent or untrue, either before or after the examination or after my admission to the
programme, I understand that I am liable to face criminal prosecution and the
management can claim all authority to cancel my candidature / selection or admission
as the case may be and I would have to forego my seat and the fees.
I agree to abide by the rules and regulations governing the examination as well as the
rules pertaining to the refund of tuition and hostel fees contained in the brochure.
I further undertake to submit all the required certificates as per the rule, either at the
time of counselling or during the admission process, failing which I understand that I
would have to forego my seat and the fees.
I have read the brochure and understood the contents in general and the method of
Equipercentile Equating in particular.
I accept this method to be adopted for Merit List preparation by VIT.

Signature of the Applicant

Payment Acknowledgement Copy

VIT ONLINE APPLICATION SALE

Payment Option Made:-NetBanking / Credit Card / Debit Card.

Bank Reference No.:201412026765339

Transaction No.:130789194

Applicant Name:SOUMYA ROY CHOUDHURY

Application No.:2015016070

Contact No.:9864853488

Transaction Date:02-12-2014 10:58:39

Application Fee :

940.00 (excluding bank charges.)

Amount in words: Rupees Nine Hundred And Forty Only.

Note :
1. Do not send the hardcopy of the application form.
2. Retain a photocopy of the completed application form with you.