Form No.

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Application Form
B.Tech Program (2011-12)
Computer Science and Engineering

Information and Communication Technology

Biotechnology

Electronics and Communication Engineering

(Rank the above as per your preference. Example: 1,2,3,4)

Student’s Name Mobile No.

Father’s Name Mother’s Name

Test Appeared/Appearing for JEE AIEEE NU Online Exam

Roll Number

Rank

Online Test Centre Code

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Instructions
1. Read the application form carefully before you fill it.
2. Please use tick ( ) in a appropriate boxes where ever required, except for questions where you need to list in numbers.
3. The application form will be attended to only if all the required information is included. Please re-check the form to ensure you have not left any data
un-filled.
4. All information you provide will only be used by our Admission Department and will remain strictly confidential.

Personal Data
First Name Middle Name Last Name

Father’s Mobile No. Tel. no. (O)

Mother’s Mobile No. Tel. no. (O)

Father’s Email ID

Mother’s Email ID

Gender Male/Female Blood Group

Date of Birth (DD/MM/YY) Category– Gen/SC/ST/ OBC/ Phy Handicap

Mailing Address

City or Town

State Country Pincode

Permanent home phone, STD code first

E-Mail Address Mobile

Medical History if any

Academic Qualification
Class X Details Class XII Details
Subjects Percentage Subjects Percentage

Aggregate of all subjects Aggregate of all subjects

Year of Passing : Year of Passing :

Name of School : Name of School :
Name of Board : Name of Board :
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Academic Honours
(Briefly describe any scholastic awards or scholarships you have won)

Extra-curricular Activities
(Briefly describe any extra-curricular, personal and voluntary activities you have pursued.)

Preferences
Which of the following activities would you like to be part of (Choose any two):
Cultural Publicity Sports Seminar Conferences

Why do you wish to join NIIT UNIVERSITY?

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How did you get to know about NIIT UNIVERSITY?

Newspaper : (Name) Internet : Website

Magazine : (Name) Friends/Relatives

Coaching Institute : (Name) Any other, please specify.

Have any of your friends been studying/teaching/employed at NIIT UNIVERSITY? If yes, specify.

Name

Program

Have you applied elsewhere? If yes, please give details:

Personal Statement

This personal statement helps us become acquainted with you in ways different from courses, grades, test scores and
other objective data. It will demonstrate your ability to organize thoughts and express yourself. We are looking for
responses that will help you know better and as a student, Please describe yourself to your classmates.

Declared by Applicant:

I have gone through the Admission and Fees Policy. I shall abide by all the condition laid therein. I declare that all
information in my application is complete, factually correct, and honestly presented. I agree to the condition that if any
information or statement is found to be incorrect, my admission will be automatically cancelled.

Signature Date

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Detailed Information on NU Online Examination Centre for B.Tech in Biotechnology are as under:-

Date : 29-06-2011
Duration : 1 hr
Nature : Objective questions
Marking : No negative marking
Location : The test as well as interview will be conducted at some or all of  the following locations:

List of Locations with Codes:-

North  East West South

[N1] Chandigarh [E1] Bhubaneshwar [W1] Ahmedabad [S1] Bangalore
[N2] Delhi [E2] Guwahati [W2] Bhopal [S2] Chennai
[N3] Jaipur [E3] Jamshedpur [W3] Mumbai [S3] Hyderabad
[N4] Lucknow [E4] Kolkata [W4] Nagpur [S4] Mysore
[N5] Ludhiana [E5] Patna [W5] Nasik [S5] Vizag
[E6] Ranchi [W6] Pune
   
 

Check-list for the Candidate

1. Class X mark-sheet and date of birth certificate
2. Class XII mark-sheet and certificate
3. JEE, AIEEE, NIIT UNIVERSITY Online test results (which ever applicable)
4. Five passport size photographs. (one pasted on the form, two pasted on the admit card of the NU Online
Examination and two to be separately enclosed with the form)

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