MES INSTITUTE OF TECHNOLOGY & MANAGEMENT, CHATHANNOOR Chathannoor P.O., District, State, PIN – 691 572 Phone:0474-2022761 (Off.) 9446569478, 0474-2590700 (Principal) Tele Fax :0474-2590700 Website : www.mesitam.ac.in e-mail: [email protected]/[email protected] APPROVED BY AICTE/GOVT. OF KERALA AFFILIATED TO APJ ABDUL KALAM TECHNOLOGICAL UNIVERSITY Run by the Muslim Educational Society (Regd.) Calicut Application for Admission to B.Tech Note: Please read the instructions carefully before filling the application form, No column should be left blank

Application No. Downloaded from website Paste your

Register No.(MESITM) passport size photograph here. For Office use only Do not attest/staple Signature of Candidate

1. (a) Name of the applicant in full (Block Letters as in SSLC)

(b) Gender Male / Female

(c) Date of Birth

(d) Nationality (e) Blood Group

(f) Category SC / ST / OBC / OEC / General (g) Religion & Caste (h) If eligible for Kerala state communal reservation (SEBC), EZ / MU / LC / BX / BH (i) Community which category do you belong to ? 2. Communication Address Permanent Address

Pin Code Pin Code e-mail Phone Mobile

3. (a) Name and Occupation of Father

(b) Name and Occupation of Mother

(c) Name and Occupation of Guardian

(d) Annual family income (Rupees)

(e) Name & Address with Phone No. of local guardian, if any

4. Are you a native of Kerala? If not, which state/place do you belong to? Yes/No.

5. Details of SSLC Examination or Equivalent

Marks Percentage Board Register No. Month & Year of Examination

6.(a) Details of Qualifying Examination Appeared/ Passed Name & Address of Month & Year of Mark Maximum % of Register No Subject School/ College attended Examination Secured Marks Marks Physics

Chemistry

Mathematics

Sub Total

Total for all subjects

(b) Transfer Certificate No. (c) Date of Issue

7. Entrance Test Roll Number Total Marks Secured Rank Number 8. Whether seeking admission under NRI Quota?

(If Yes, indicate relationship with NRI) 9. Branch to which admission is sought (Specify order of priority in the boxes: 1,2,3,4,…..etc)

UNDER GRADUATE

Civil Engineering Electrical & Electronics Engineering

Computer Science & Engineering Mechanical Engineering Electronics & Communication Engineering

11. Application fee paid Receipt No. Dt. Rs.

DD No. Dt. Rs.

DECLARATION I hereby solemnly and sincerely affirm that the statements and information furnished above and in the enclosure submitted by me are true. I also solemnly affirm that I have read the information brochure and the conditions stated therein are agreeable to me. If any of the information furnished herein is later found to be untrue in material particulars or in any other manner, I am aware that I am liable to criminal prosecution; I am ready to forgo my seat in such cases. I am also aware that fees once paid will not be refunded. I hereby undertake of abstain from any act of ragging whatsoever during the period when I shall be a student of MES Institute of Technology and Management, Chathannoor.

SIGNATURE OF THE APPLICANT SIGNATURE OF PARENT /GUARDIAN Place :…………………………………………………. Date :…………………………………………………. THIS COLLEGE EXERCISES ZERO TOLERANCE TO RAGGING If any incident of ragging comes to the notice of the authority, the concerned student shall be given the opportunity to explain. If the explanation is not found satisfactory, the authority would expel the student from the institution.