Government Engineering College, Banda

A Constituent College of Dr. A.P.J. Abdul Kalam Technical University U.P. Lucknow

ONLINE STUDENT REGISTRATION SYSTEM

APPLICATION FORM FOR REGISTRATION 2016-17

Branch B. Tech. Mechanical Engineering

Semester 5
Roll No. 1573440915
Name VIJAY BAHADUR PAL
Father's Name SHIV LOCHAN PAL
Mother's Name PREM DEVI
DOB 08/08/1994
Gender Male
Category SC
Email Address VIJAY080894@GMAIL.COM
Mobile No. 9935672472
Father's/Guardian's Mobile No. 9198651092
Father's/Guardian's E-mail Address
Correspondence Address VILL CHAUKTHA NARVAR POST AUNTA DISTT ALLAHABAD

VILL CHAUKTHA NARVAR POST AUNTA DISTT ALLAHABAD

Permanent Address

Father's/Local Guardian's Address VILL CHAUKTHA NARVAR POST AUNTA DISTT ALLAHABAD

Hosteler Request Yes

Sl. No DD No DD Data Bank Name Amount

1 734022 1-Aug-16 PNB 9500

2 734114 2-Aug-16 PNB 12500

Declaration : I undertake that the information submitted is true to the best of my knowledge and belief. I shall bear the
consequences if any of them are found to be wrong.
Undertaking by the Student: I will attend all the classes from the opening day of the College and I will be regular and
punctual to all the classes i.e (Theory/Practical) and I am aware that if I dont secure attendance more than 75% I shall be
detained and not allowed to appear for the Term End Examination.

Student (Seal and Signature) (Seal and Signature) (Seal and Signature)

Signature Faculty Advisor Head of Department Dean Academic

Note : You have to submit this print out to the College for validating your Registration

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