NATIONAL INSTITUTE OF TECHNOLOGY PATNA

Ashok Rajpath, Patna-800005.Bihar.India

Application form for Admission to
B. Tech. / B. Arch. / Integrated M.Sc. Programme

Institute Roll No.

(to be assigned by office)
To be filled by the candidate in his/her own handwriting in Capital letters except signature PHOTOGRAPH Affix
recent coloured passport size
Details of fee paid Challan No./ photograph
Amount
Transaction ID
And
Put your signature in box
JEE Mains 2018 Roll No. Candidate Allotted provided below this space in
Black pen
Category (Put √ Category (Put √
mark) mark)
JEE Mains 2018 Rank (All India) General General
JEE Mains 2018 Rank (Category) OBC-NCL OBC-NCL

JEE Mains Exam Subjects SC SC

ST ST
PwD PwD
Resident of State: OCI/PIO
Blood Group
Allotted Course and Branch B. Tech./ B. Arch. / Integrated M. Sc. Programme
Seat Pool Gender Neutral/Female
1. Name of candidate in full
(as per 10th Certificate)
Name of candidate in Devnagari
(Hindi)

2. Father’s Name
3. Mother’s Name
4. Guardian’s Name in full
(if father is not alive)
5. Date of Birth (dd-mm-yyyy) Sex: Male / Female/Trans
6. Occupation of Parents Father: Mother:
Parent’s Income per annum from all
sources
Organization where father/Mother/
Guardian (if father is not alive) is
working
7 Correspondence Address

Pin Code:
Phone No. (with STD Code)/Mobile
No.:
Email ID:
8. Permanent Address

Pin Code

Pin Code:
9. Academic Details:
Exam Branch / Specialization Institute / University Year of Passing
Matriculation/10th
Intermediate/12th
10. SGPA/CGPA/ % Marks: SGPA/ CGPA % Marks Overall % Marks
Matriculation/10th
Intermediate/12th
11. Declaration of the candidate:
I,………………………………………………………….Son/Daughter of Sri……………………………………
Declare that : -
a) Information furnished above are correct and in case any of the information is found false or forged at any stage
of my admission to and/or stay in the Institute, I shall be liable (i) to lose my candidature for admission to the
program, (ii) for expulsion from the Institute if admitted and (iii) for appropriate legal action.

b) In the event of my being admitted to this Institution, I shall abide by all the rules and regulations of the Institute
and the authority concerned.

c) I have submitted my qualifying examination passing certificate with the application form

OR

I will submit my qualifying examination passing certificate by the due date notified by the Institute, else my
admission shall stand cancelled.

Place :

Date : Full Signature of the Candidate in English

12. Declaration of the Father / Guardian: Candidates may submit the declaration of Father/Guardian in their own
handwriting separately even after admission if Father/Guardian is not available at the time of admission.
I,……………………………………………………. declare that in the event of Sri/Smt./Miss……………………
…………………………………………..being admitted to this Institution, I shall be responsible for his/her conduct and
undertake to pay all his/her Institute, Hostel, Mess and other dues regularly till the completion of his/her studies. I further
certify that the information furnished by him/her are correct.

Place :

Date : Full Signature of the Father / Guardian

 Name of the candidate in full Roll No. :

1. Self-attested Photocopies of following(as applicable) must be submitted at (Put √ mark)

the time of Admission

(i) CSAB Reporting letter and allotment letter

(ii) JEE (Mains) Score Card
(iii) Certificate of Category OBC/SC/ST, if applicable, issued by the competent
authority
(iv) Income Certificate for OBC Candidates for claim with respect to Non creamy
Layer issued by competent authority as per directive of the MHRD. (If seat
allotted in OBC-NCL Category )
(v) Certificate for Person with disabilities
(vi) Class X (High School) Board Certificate as proof of Date of Birth
(vii) Class X Marks Sheet
(viii) Qualifying Examination (XII) Marks Sheet
(ix) Qualifying Examination passing certificate (as applicable for the program). In
case it is not being submitted then undertaking for submission by due date fixed
by Institute.
(x) Affidavit with respect to Gap year (i.e. reason for discontinuity between passing
year of qualifying examination and year of admission to B. Tech/ B. Arch/
Integrated M. Sc program.)
(xi) Income certificate of parent issued by revenue officer not below the rank of
Tahsildar.
(xii) Two copies of colored Photograph. (identical to one pasted on the application
form)
(xiii) Migration certificate from the University/ Deemed University/ Institute last
Attended
(xiv) Balanced fee payment.
2. Name and Signature of documents Verifying officer:

(To be obtained at the time of admission in presence of Institute representative only)

3. Full Signature of the Candidate: (English)

Left Thumb impression of the Candidate

Signature of Admission-In-Charge of the Institute

 NATIONAL INSTITUTE OF TECHNOLOGY PATNA
(An Institution of National Importance under MHRD, Govt. of India)
Ashok Rajpath, Patna-800 005, India
…………………………………………………………………………………….………………………………………………………………………………
MEDICAL EXAMINATION FOR PHYSICAL FITNESS
(To be obtained from any Registered Medical Practitioner)

Name: ………............................................................. S/O........................................................................................

I. General Examination: …………….. ……… Height …………cms. Weight ………....Kgs.

II. C.V.S. : Pulse: ……………/ Minute; Regular / Irregular B.P.: …………………………..

III. Respiratory System: ……………………………………………………………………………………..

IV. GI System: ………………………………………………………………………………………………

V. Musculoskeletal System : Normal / Disabled (If disabled refer to a specialist)

VI. Skin: ………………………………………………………………………………………………….….

VII. Examination of Eyes: Normal / Defective: ……………………… Spectacles………………………….

(If any abnormality is found, refer to the specialist)

VIII. E.N.T.: Normal / Abnormal: …………………………………..

(If any abnormality is found, refer to the specialist)

IX. C.N.S.: ………………………………………………………………………….……………………….

X. G.U.S.: …………………………………………………………………………………………………..

XI. Female Candidate: Menstrual History: ………………………………………………………………….

XII. Blood Group & Rh: ……………………………………………………………………………………..

I do hereby certify that I have examined the above candidate for admission to ……………………….. Programme
in National Institute of Technology Patna, ………………………… department and cannot discover that he / she
has any disease and constitutional defect or bodily infirmity except that
……………………………………………… I do not consider this as a disqualification for undergoing the above
programme. His / Her age according to his/her own statement is ………………………. years and by appearance
……………. years.

Personal Marks of Identification:

1…………………………………………………………….……..

2……………………………………………………………………

Date:

Place: Signature of Doctor

(With seal & Regd.No.)

(* Any defect to be noted in Detail)

 NATIONAL INSTITUTE OF TECHNOLOGY PATNA
(An Institution of National Importance under MHRD, Govt. of India)
Ashok Rajpath, Patna-800 005, India
………………………………………………………………………………………………………………………………………………………........................
CERTIFICATE OF PHYSICAL FITNESS
(Declaration by the candidate for the issue of Physical Fitness Certificate)

Name: …………………………………………………………… Male/Female Branch: …………………………

Date of Birth: Age (in years):

Address: ………………………………………………………………………………………………………………

………………………………………………………………………………………………………………..

Indicate your response by Y/N (Y means Yes; N means No)

Do you have any minor or major complaint?
If yes, describe …………………………………………………………………………

Are you allergic to any medicine or any others?

If yes, describe …………………………………………………………………………

Have you ever been affected with?

Small Pox, Chicken Pox Asthma

Intermittent or any fever Epilepsy

Enlargement or suppuration of glands Appendicitis

Spitting of Blood Lungs Disease

Heart Disease Rheumatism

Fainting Attacks Any Other ……………………

Have you ever had any operation or been advised any operation?

If yes, describe …………………………………………………………………………………………..

Are you handicapped? Visual / Hearing / Orthopedic

…
Immunization had: BCG OPV DPT M.M.R. …………
Preventive vaccination (Please tick):
Chicken Pox Typhoid Hepatitis-B
Rubella (F) Any other (specify)…………………………

Blood Group & Rh ………………………………………………………………………………………………….

Personal Marks of Identification: 1...……………………………………………………………………………….

2. …………………………………………………………………………………

I declare that all the above information are true and to the best of my knowledge.

Signature of the Candidate

 AFFIDAVIT BY THE STUDENT
I, (full name of student with
s/o d/o Mr./Mrs./Ms.
admission/ registration/ enrolment number)
, having been admitted to National Institute of Technology Patna (name of the institution) ,
have received a copy of the UGC Regulations on Curbing the Menace of Ragging in
Higher Educational Institutions, 2009, (hereinafter called the “Regulations”) carefully read and
fully understood the provisions contained in the said Regulations.
2) I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes
ragging.
3) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of
the penal and administrative action that is liable to be taken against me in case I am found guilty of
or abetting ragging, actively or passively, or being part of a conspiracy to promote ragging.
4) I hereby solemnly aver and undertake that
a) I will not indulge in any behavior or act that may be constituted as ragging under clause
3 of the Regulations.
b) I will not participate in or abet or propagate through any act of commission or
omission that may be constituted as ragging under clause 3 of the Regulations.
5) I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause
9.1 of the Regulations, without prejudice to any other criminal action that may be taken against
me under any penal law or any law for the time being in force.
6) I hereby declare that I have not been expelled or debarred from admission in any institution in the
country on account of being found guilty of, abetting or being part of a conspiracy to promote,
ragging; and further affirm that, in case the declaration is found to be untrue, I am aware that my
admission is liable to be cancelled.
Declared this _day of month of year.
Signature of deponent
Name:
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit
is false and nothing has been concealed or misstated therein.
Verified at (place) on this the (day) of (month) , (year ) .

Signature of deponent
Solemnly affirmed and signed in my presence on this the (day) of (month), (year) after reading the contents
of this affidavit.

OATH COMMISSIONER
 AFFIDAVIT BY PARENT/GUARDIAN
I, Mr./Mrs./Ms. (full name of
parent/guardian) father/ mother/ guardian of , (full name of
student with admission/ registration/ , having been admitted to National Institute of
enrolment number)
Technology Patna (name of the institution) , have received a copy of the UGC Regulations on Curbing the
Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the “Regulations”),
carefully read and fully understood the provisions contained in the said Regulations.
2) I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging.
3) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of
the penal and administrative action that is liable to be taken against my ward in case he/she is found
guilty of or abetting ragging, actively or passively, or being part of a conspiracy to promote ragging.
4) I hereby solemnly aver and undertake that
a) My ward will not indulge in any behaviour or act that may be constituted as ragging under
clause 3 of the Regulations.
b) My ward will not participate in or abet or propagate through any act of commission or
omission that may be constituted as ragging under clause 3 of the Regulations.
5) I hereby affirm that, if found guilty of ragging, my ward is liable for punishment according to clause
9.1 of the Regulations, without prejudice to any other criminal action that may be taken against my ward
under any penal law or any law for the time being in force.
6) I hereby declare that my ward has not been expelled or debarred from admission in any
institution in the country on account of being found guilty of, abetting or being part of a
conspiracy to promote, ragging; and further affirm that, in case the declaration is found to be untrue, the
admission of my ward is liable to be cancelled.
Declared this day of month of year.
Signature of deponent
Name:
Address:
Telephone/ Mobile No.:
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit
is false and nothing has been concealed or misstated therein.
Verified at (place) on this the (day) of (month) , (year ) .

Signature of deponent
Solemnly affirmed and signed in my presence on this the (day) of (month)
(year ) after reading the contents of this affidavit.

OATH COMMISSIONER
To
The Notary Public
-----------------------

Affidavit for Gap Year

I…………………………………………………………………………………………………………………

S/O……………………………………………………………………………………………………………….

Resident of……………………………………………P.O. …………………………………………………….

P.S. …………………………………………………District …………………………………………………..

do hereby solemnly declare and affirm as follows:-

1. That I have passed the qualifying examination ………………………………………………………...

from ……………………………………………………………….in the year…………………………

2. That after passing the aforesaid examination I have not taken admission in any college/ school/ institution

during the period from…………………………………………………. till this date.

3. That after passing of the qualifying examination, I was not involved in any criminal offence during the

period from ………………………………………………till this date.

4. That from……………………………………the date of reporting/ admission to ………………….the date

of reporting for attending classes, I was sick and was under treatment of Dr. ……………………………..

That the contents of this affidavit are true and correct to the best of my knowledge and belief.

Signature of the candidate/Deponent

I identify the deponent who signed in my presence.