JIET GROUP OF INSTITUTIONS

(A Constituent of Arun Shanti Education Trust, Jaipur)

JIET Universe, N.H. 65, Mogra, Pali Road, Jodhpur-342802(Raj.)
Tel.: 0291-2868152/53, E-mail: info@jietjodhpur.ac.in | Web: www.jietjodhpur.ac.in

Session 2016-17

Name of Institute:
Course:
Branch:
Institute Registration No:
University Enrollment No:
Name of Student:
Gender:
Religion:
Father's Name:
Father's Profession:

Application No.: H-61640083

JODHPUR INSTITUTE OF ENGINEERING. & TECHNOLOGY
Bachelor of Technology
Year Applied For: IV Year
Mechanical Engineering
JIET/ME/13/006
University Roll No: 13EJIME120
13E1JIMEM45P120
VIKASH KUMAR PATEL
Male
Date of Birth:
01/01/1996
HINDU
Category:
OBC
Mr. DILIP SINGH
Self Employed

Mother's Name:
Mrs. ANITA DEVI
Total Annual Income (In rupees):
60000

Contact Detail's
Permanent Address: VILLAGE UCHAILA,, DIST. ROHTAS POST. ROHTAS ,
ROHTAS
Pincode
821311
Father Mobile No:
9931428529
Parent's E mail Id:
Present Address:
43/1 JODHPUR INSTITUTE OF ENGINEERING AND TECHNOLOGY
JODHPUR
Pincode
342002
Student's Mobile No: 9784562468
Student's E mail Id: vikash.13JIME120@jietjodhpur.ac.in
Facility Opting :
Hostel

JIET GROUP OF INSTITUTIONS

JODHPUR INSTITUTE OF ENGINEERING. & TECHNOLOGY
RECEIPT FOR STUDENT REGISTRATION FORM SUBMISSION
SESSION 2016-17
The Application No. H-61640083 of Mr. VIKASH KUMAR PATEL Registration No. JIET/ME/13/006 of
Mechanical Engineering Branch for IV year has been recieved.

Date:-

Authorized Signature

JIET GROUP OF INSTITUTIONS

(A Constituent of Arun Shanti Education Trust, Jaipur)
JIET Universe, N.H. 65, Mogra, Pali Road, Jodhpur-342802(Raj.)
Tel.: 0291-2868152/53, E-mail: info@jietjodhpur.ac.in | Web: www.jietjodhpur.ac.in

Session 2016-2017

Name of College :-

JODHPUR INSTITUTE OF ENGINEERING. & TECHNOLOGY

Course

:-

Bachelor of Technology

Branch/Year

:-

Mechanical Engineering/IV Year

Name of Hostel :-

Room No :-

1. Name of Student (Mr./Ms.):-

VIKASH KUMAR PATEL

2. Father's/ Mother's Name :-

DILIP SINGH

3. Parent Address

:-

VILLAGE UCHAILA,, DIST. ROHTAS POST. ROHTAS

, ROHTAS
Tel No.: Residence :Office :Mobile No :-9931428529
4. E-mail ID
:vikash.13JIME120@jietjodhpur.ac.in
5. Local Gurdian's Name & Address :Tel No.: Residence :Office :Mobile No :6. Mention if suffering from any chronic Disease or allergy(if yes furnish detail)
______________________________________________________________________________________________
______________________________________________________________________________________________
Yes I want to take addmission in JIET Hostel and I undertake to abide by all rules and regulations of JIET
Management

Signature of Parent / Local Guardian

Date:-19/06/2016

Signature of Student

UNDERTAKING
(For Registration in new session)
(Session 2016-2017)
I VIKASH KUMAR PATEL S/o Sh. DILIP SINGH wish to get my self registered for the (Branch/
Year/Course) Mechanical Engineering/ IV Year.
I declare that all the above details are true to the best of my knowledge. If the details are found to
be incorrect at any stage, I am liable to any action taken by college authorities.
I understand that a minimum of 75% attendance is required to make myself eligible for taking
Mid-term and University Theory and Practical examination failing which I shall not be allowed to take the
Mid-Term and University Theory and Practical Examination.
As a student of JIET Group of Institutions, I understand my role and responsibility of Maintaining
discipline and decorum. I declare that I will abide by all the disciplinary rules of the college and if found guilty
of any kind of in disciplinary activity then will accept the decision taken by the management of the college.
I am also aware that important information are sent on mobile via SMS at times. I agree to receive SMS
sent by JIET Group of Institutions. I shall report at Student cell in case I don't receive SMS on mobile/SIM Change.

(Signature of Student)

(Signature of Father/Gaurdian)

Date:-19/06/2016

The following documnets must be attached with this form:[

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Photocopy of all university examination mark sheet(Till Date)

Certificate regarding membership of professional society.
Certificate regarding publication.
Certificate regarding participation in technical events.
Certificate regarding participant in sports events.
Certificate regarding participant in competitive exams.
Certificate regarding projects undertaken (Syllabus and off Syllabus).
Certificate regarding training (Curriculum or beyond curriculum).
Any other achievement certificate(s).
Anti-ragging undertaking duly attested by notary.

(Student Signature)

ANTI RAGGING UNDERTAKING

(As per the provisions of Anti - Ragging Verdict by the Hon'ble Supreme Court)
Session 2016-2017

I VIKASH KUMAR PATEL S/o Sh. DILIP SINGH Roll No.13EJIME120

Student of B.Tech (Mechanical Engineering) / Session (2013-2017) has been admitted at
JODHPUR INSTITUTE OF ENGINEERING. & TECHNOLOGY, Jodhpur, have gone through AICTE Regulation
on Curbing the Menace of Ragging in Higher Educational Institutions,(here in after called the "Regulation")
carefully read and fully understood the provisions contained in the said Regulations.
1.

I have, in particular, perused Clause 4 (on AICTE website) of Regulation and am aware as to constitute
ragging.

2.

3.

I have also, in particular, perused Clause 5(3) (on AICTE website) and Clause 8(4)(a) (on AICTE website) of
the Regulation andam fully aware of the penal andadministrative action that is liable to be taken against me
in case I am foundguilty of or abetting ragging, actively or passively, or being part of conspiracy to promote
ragging.
I hereby solemnly aver and undertake that
a) I will not indulge in any behavior or act that may be constituted as ragging under Clause 4 (on AICTE
website) of the Regulations.
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 4 of the Regulations.

5.

I hereby solemnly affirm that, if found guilty of ragging, I am liable for punishment according to Clause 8(4)(a)
of the Regulations, with out prejudice to any other criminal action that may be taken against me under any
panel law or any law for the time being in force.

6.

I hereby declare that I have not been expelled or debarred from admission in any institution in the country
on account of being fount guilty of, abetting or being part of a 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:-19/06/2016
I hereby fully endorse the undertaking made by my son/daughter/ward.

(Attestation by Notary/Oath Commissioner)

Date:-

(Signature of Student)

(Signature of Father/Mother or Guardian)

Name:Contact No.:Date:-