Application form for VITEEE - 2016

Full Name

: YASHASWI PATHAK

Application. No. : 2016146445

Date of Birth

: 20/01/1998

Gender

: MALE

Religion

: Hinduism

Nationality

: Indian

Community

: General/OC

Mother Tongue

: Hindi

Native State

: Bihar

Mode of Study

: Regular

Landline No.

: -

Mobile No.

: 9006291343

Parent name

: DR.ANITA PATHAK

Hostel

: Yes

Choice of Campus

: Vellore

Email ID.

: yashaswi.kanu@gmail.com

Qualifying Exam

: 12th Class

Month & Year Passing

: Mar - 2016

Exam Roll.No./Reg.No.

Testcity

: PATNA

Permanent Address

: 187 MIG HANUMAN NAGAR, KANKARBAGH,PATNA,PATNA,BIHAR,800020.

Name of the School

: DELHI PUBLIC SCHOOL,PATNA

Address of the School

: VILL.CHANDMARI, PATNA, PATNA,BIHAR, 800020.

DECLARATION
I solemnly and sincerely affirm that I am an Indian National and that all particulars furnished
by me in this application form are true and correct. I have not concealed any information.
However, in the event of any information being found to be incorrect, fraudulent or untrue,
either before or after the examination or after my admission to the programme. I understand
that I am liable to face criminal prosecution and the management can claim all authority to
cancel my candidature / selection or admission as the case may be and I would have to
forego my seat and the fees.
I agree to abide by the rules and regulations governing the examination as well as the rules
pertaining to the refund of tuition and hostel fees contained in the brochure.
I further undertake to submit all the required certificates as per the rule, either at the time of
counselling or during the admission process, failing which I understand that I would have to
forego my seat and the fees.
I have read the brochure and understood the contents in general and the method or
Equipercentile Equating in particular. I accept this method to be adopted for Merit List
preparation by VIT.
I understand that all information related to VIT application form and VIT exam will be only
sent through the valid mobile numbers as provided by me in the same form.
I am also aware that the counselling fee of Rs.10,000/- is non-refundable.
Date :
Place :

Signature of the Applicant

Payment Acknowledgement Copy

VIT ONLINE APPLICATION SALE

Payment Option Made:-NetBanking / Credit Card / Debit Card.

Bank Reference No.:201601313802349

Transaction No.:202952200

Applicant Name:YASHASWI PATHAK

Application No.:2016146445

Contact No.:9006291343

Transaction Date:31-01-2016 05:53:09

Application Fee :

960.00 (excluding bank charges.)

Amount in words: Rupees Nine Hundred And Sixty Only.

Note :
1. Do not send the hardcopy of the application form.
2. Retain a photocopy of the completed application form with you.