Ambala College of Engineering & Applied Research (ACE) Devsthali, Ambala - Jagadhari Highway, P.O. SAMBHALKHA- 133101 (Ambala) Approved by Haryana Govt. and All India Council for Technical Education (AICTE) Affiliated to Kurukshetra University, Kurukshetra Ph. 0171-2821833, 2822001-003, Telefax: 2822002 Website: www.ambalacollege.com, Email: [email protected]
APPLICATION FORM FOR B.TECH ADMISSIONS 2014-15
For Office Use Only: Form Received on: ______Registration No.______
BRANCH APPLIED FOR (in order of Preference place 1,2,3,4 in the Box): Biotechnology Engineering Computer Science & Engineering Electronics & Communication Engineering Mechanical Engineering 1. NAME IN FULL
2. EMAIL ID
3. ADDRESS:
4. MOBILE NO PASTE YOUR
5. DATE OF BIRTH D D M M Y Y Y Y RECENT PASSPORT SIZE 6. GENDER MALE FEMALE PHOTOGRAPH
7. NATIONALITY
8. BLOOD GROUP
9. CATEGORY GEN/ SC/ ST/ BC-A/ BC-B/ OBC
10. FATHER’S NAME
a). OCCUPATION b). DESIGNATION
OFFICE /BUSINESS ADDRESS:
PH MOBILE:
11. MOTHER’S NAME
a). OCCUPATION
b). DESIGNATION
c). OFFICE ADDRESS
PH C O D E Mobile
12. STATE OF DOMICILE
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13. DETAILS JEE-2014 LEET-2014 ROLL NO RANK (Overall All India Rank)
14. Details of Qualifying Examination: NAME OF BOARD/ YEAR ROLL NO. SCHOOL/ CITY STATE/UT SUBJECT MARKS MAX EXAMINATION UNIVERSITY POLYTECHNIC OBTAINED MARKS Physics
Chemistry
Mathematics/ Biology
Total PCM/PCB English
Aggregate Percentage in 10+2______Percentage in PCM/PCB______
15. Percentage in 10th or equivalent exam: ______
16. Compartments in 10+2/Diploma Exam, if any (YES/NO) Details, if yes: i. Subjects: ii. Passed in first attempt: (YES/NO) iii. Pending Compartment, if any______17. Ever disqualified from exam/studies (YES/NO)
18. A) Guardian’s Name & Address (Local if any)
Ph. C O D E Mobile
B) Relationship: ______
19. Annual income of father or guardian ______
20. Area which you belong to RURAL/URBAN
21. Whether applied for Hostel YES/NO
22. Whether applied for Bus facility YES/NO If yes, then tick your Boarding Station. Ambala City Ambala Cantt Shahabad Markanda Saha/Mithapur Kurukshetra Yamunanagar/Jagadhari Barara Dosarka B’wala/N’garh/Sehzadpur
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23. Undertaking for admission In case my son/daughter/ward is admitted, I undertake that I will make all due payments as laid down by the college in time. I solemnly declare that the information provided by me in the Admission Form is correct and I have not concealed any relevant facts. I undertake to abide by all the rules, regulations and instructions of Kurukshetra University and this College. I am taking admission in this college provisionally at my own risk and responsibility subject to the confirmation of my eligibility by the University. If at any stage, I am declared ineligible and if my admission is cancelled by the University under the rules, I will have no claim for it. Further, I undertake not to take part in any political activity/agitation whatsoever directly or indirectly.
I undertake that I shall not indulge in any act of ragging. Also I have never been involved in any unlawful activities.
Signature of Candidate Signature of Parent/Guardian
Name______
24. ENCLOSURES: (Tick ‘Yes or No’ as applicable) S. No Enclosure Description (attested copies only) YES NO 1 Admit Card JEE 2014/LEET 2014 2 Result Card JEE 2014/LEET 2014 3 10+2 or Diploma pass Certificate 4 Detailed Marks Certificate (10+2)/Diploma or equivalent exam 5 Migration Certificate 6 Character Certificate (From the Institution of qualifying exam or Institute last attended) 7 Matriculation Certificate/Proof of age 8 Medical Fitness Certificate (From Government Hospital) 9 Supporting proof of reservation if any.
25. DECLARATION: Certified that all the entries made in this form are correct
Date Signature of Candidate Signature of Parent/Guardian
For Office Use Only Admitted to (Branch):______
EXAMINATION MARKS RANK JEE LEET
PCM/PCB % ______Remarks, if any:
Final Merit:______Scrutiny Officer/Principal 3