APPLICATION FOR ADMISSION TO COURSE FOR THE ACADEMIC YEAR

Application No.:
1.General Details
Name(as in SSLC/10th marks card)
Gender
Father's/Guardian's Name
Mother's Name
Father's/Guardian/Self Occupation
DOB Age Blood Group
Annual Income in
Anusha V A
Female
14-06-1993 21 A+Ve
Anthony V J
Lilly P T
BSNL EMPLOYEE 446000
2.Address
Line1
Line2
City
State
Pin Code
Tel No.
Mobile No.
Email Id
Telephone Exchange, Near Headpost office
Madikeri
Madikeri
Karnataka
571201
08272-220888
9482603929
anushaanthony06@gmail.com
Chamundeswarinagar
Madikeri
Madikeri
Karnataka
571201
08276-274686
Local Permanent
3.Caste and Category
Nationality
Religion Caste
Sub Caste Category G\R\U\K
Indian Christian Christian
NONE
3BG
General
4.Pre-University/10+2/Dip/UG Qualification details (Last attended):
Reg No.
Year of
Passing
Name of College Qualification TC No.
Branch/Course Board/Uni State
402CS11
003
2014
Caveri Polytechnic,
Gonigoppal
Diploma Computer
Science
Board of
Technical
Examination
Karnataka
5.CET/COMED-K/MQ/PGCET DETAILS
Subject Name Maximum Pass Marks Marks Obtained
V Sem 775 616
VI Sem 750 604
Total 1525 1220
Percentage(%) 80.00
Admission Date: 30-07-2014
UG 2014
-
2015
2014UG0250
NIE Institute of Technology
Koorgalli,Mysore-570 018
Page 1 of 5 Print Date: 29/07/2014 11:55 PM
ADM Quota Adm Ord No.
Adm Ord Date
REG No.
Rank
Claimed CAT
Allotted CAT
Branch
Fee Paid at
CET/PGCET in
CET
U5462
4306
1410003264
3BG
Computer Science and Engineering
28-07-2014
3BG
41590.00
6.List of Documents Retained at College
Name Of The Document Original(Y/N) No. of Copies Date Received Remarks
CET Allotment Letter Y 3 30 Jul 2014
Passport Size Photo Y 3 30 Jul 2014
STUDY CERTIFICATE Y 3 30 Jul 2014
Transfer Certificate Y 3 30 Jul 2014
SSLC Marks card Y 3 30 Jul 2014
CASTE CERTIFICATE Y 3 30 Jul 2014
Income Certificate Y 3 30 Jul 2014
DIPLOMA ALL ORIGINAL
MARK
Y 3 30 Jul 2014
Diploma Original Provisional
Certificate
Y 3 30 Jul 2014
7.Declaration by the Student
All the particulars furnished above are true to the best of my knowledge and belief. I understand that association
whether active or passive with unlawful organization is forbidden. I promise to abide by the rules and the discipline
of the college in which I am admitted and I also declare that I will not work anywhere during my studentship.
Signature of the Parent or Guardian
Date:
Signature of the Candidate
8.Verification by College Office
1.Verified & found correct:
2.Verified with following comments:
YES NO
a)
b)
Case Worker Superintendent Registrar
9.Fee Details
Receipt No.: Date: Amount in
ORDERS OF THE PRINCIPAL
Provisionally admit
to Semester
PRINCIPAL
1939 30-07-2014 12600.00
Anusha V A
3 BE Computer Science and Engineering
Page 2 of 5 Print Date: 29/07/2014 11:55 PM
NIE Institute of Technology,MYSORE - 570018
UNDERTAKING
I. I hereby promise that:
1. I will not deliberately abstain from classes, tests and examinations.
2. I will not participate in any strikes or demonstrations and will not induce others to do so.
3. I will not indulge in any act which will result in damage or loss to college.
4. I will not indulge in any act which will lower the prestige of the college.
5. I will not conduct myself in any manner which shows disrespect to any staff member of the
college or my classmates.
6. I will utilize the library and other facilities of the college with care.
7. I will abide by the rules and regulations of the college.
8. I shall clear all dues pertaining, to the college towards tuition and other fees and to the hostel
towards boarding and lodging fees in time. I shall also make arrangements to pay all the deposits
required in the college and hostel.
9. I shall vacate the hostel if I am detained at any stage, if I am a hostelite.
10. I understand that I will not be permitted to appear for the examinations, if I do not clear all the
arrears due to the college and hostel.
11. I will not indulge in any act of ragging the junior students and I will not induce others to rag
new entrant.
12. I further understand that I am liable to be punished if I violate the general code of discipline
and rules of the college, and that I have no right to question any punishment imposed on me by
the college authorities. The punishment being in the form of fine, suspension from college for
definite period, or expulsion from the college.
II. I have seen the above rules of conduct and discipline of the college and I will hold myself
responsible for any misconduct of my Ward/Son/Daughter. I shall also make all arrangements to
clear all the payments to be made by my Son/Daughter/Ward in time, without giving scope for
arrears to be developed.
I agree to abide by the Regulations/Ordinances adopted by the University and college for the
maintenance of the discipline among students in the college/Department/Institute/Hostel.I will
neither involve myself in any unlawful or provoking or communal or anti-social or political
activities nor cause physical harm to any fellow student or teacher or official. I also agree not to
involve myself in the damage of the institute or any University property.
I give this undertaking with the full knowledge that any breach of this on my part is liable
for the cancellation of my admission in the College/Department/Hostel/University at any point of
time of the four year programme.
Signature of the Parent/Guardian Signature of the Candidate
Name:
Relationship: Parent/Guardian
Principal
NIEIT,Mysore
Anthony V J
Page 3 of 5 Print Date: 29/07/2014 11:55 PM
ANNEXURE
AFFIDAVIT BY THE STUDENT
I Anusha V A
s/o d/o c/o Mr. /Mrs./Ms Anthony V J
Having been admitted to Computer Science and Engineering
have received a copy of AICTE 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 regulation.
I have, in particular, perused clause 3 of Regulations and am aware as to what constitutes
ragging.
I have also in particular perused clause 7 and clause 9.1 of the Regulation and am fully aware
of 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 conspiracy to promote ragging.
I hereby solemnly aware and undertake that
a)I will not indulge in any behavior or act that may be constituted as ragging under clause 3 of
Regulation.

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 Regulation
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.
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 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.
DATE:30/07/2014 12:00 AM Signature of Deponent


VRIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of
the afidavit is false and nothing has been concealed or misstated therein.
Verified at The NIEIT on this day 30/07/2014 12:00 AM
Signature of Deponent

Solemnly affirmed and signed in my presence on 30/07/2014 12:00 AM after reading the contents
of affidavit.

OATH COMMISSIONER
Page 4 of 5 Print Date: 29/07/2014 11:55 PM
ANNEXURE II
AFFIDAVIT BY PARENT /GUARDIAN
I.Mr./Mrs./Ms ___________________________________________________________________
father/mother/guardian of Anusha V A
Having been admitted to Computer Science and Engineering
have received a copy of the AICTE 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 regulation.
I have, in particular, perused clause 3 of Regulations and am aware as to what constitutes ragging.
I have also in particular perused clause 7 and clause 9.1 of the Regulation and am fully aware of
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 conspiracy to promote ragging.
I hereby solemnly aware and undertake that
a) a)My ward will not indulge in any behavior or act that may be constituted as ragging under clause 3
of Regulation.
b) 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.
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 me under any
penal law or any law for the time being in force.
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 conspiracy to promote ragging ; and
further affirm that, in case the declaration is found to be untrue, I am aware that the admission of my ward
liable to be cancelled.
Declared on 30/07/2014 12:00 AM
Signature of Deponent
Name:
Address:Chamundeswarinagar
Madikeri
Madikeri,Karnataka,INDIA,571201
Telephone/MobileNo:9482021199
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 The NIEIT on this day 30/07/2014 12:00 AM

Signature of Deponent
Solemnly affirmed and signed in my presence on 30/07/2014 12:00 AM after reading the contents of
affidavit.

OATH COMMISSIONER

Page 5 of 5 Print Date: 29/07/2014 11:55 PM