Registration No…….

M. Tech./M.Planning
Closing Date June 20 2011
Paste your
MALAVIYA NATIONAL INSTITUTE OF TECHNOLOGY JAIPUR 302017 Unattested
Application Form for Admission to M.Tech. /M.Planning Part Time Programme Photograph
Please read the instructions given in the Information Brochure before you filling up
the form.
Tick the relevant box wherever required
Department to which you are applying: .................................……………...
Full time with Assistantship Without Assistantship
GATE Percentile Score............... CSIR UGC/NET Employed Candidates Self Supporting
GATE Score: ............................... FT PT FT
CHOICE

Discipline:..................................... Experience in
Years........................
Programme specialization in the Department in which you are applying, preference wise
1.
2.
3.

Name (in CAPITAL) In Hindi

Gender/D.O.B. Male Female Date of Birth (dd/mm/yyyy)
Father's Name
PERSONAL

Mothers Name
Address for
Correspondence PIN
Tel No. with STD Code
E-mail# Mobile No.:
Permanent Address
CATEGORY

Category to which you belong General SC ST PH OBC

Qualifying Exam....................... Duration of the course (Years).............................. Discipline..............................

QUALIFYING DEGREE

Year of Passing......................... Name of University/ Institute …………………………………………………...

Marks Obtained Max. Marks Marks Obtained Max. Marks
Year 1 Semester I................................. .................. Semester II.......................... ..................
CGPA / Year 2 Semester I................................. .................. Semester II.......................... ..................
Marks Year 3 Semester I................................. .................. Semester II.......................... ..................
Obtained Year 4 Semester I................................. .................. Semester II.......................... ..................
CGPA............................................... on a .................................. point scale
OR aggregate % (of all the Years/Semesters) ........................

Details of Marks secured in the Examinations other than qualifying examination

Year of % Marks/
Exam./Degree Subjects Institute/University
Passing CGPA
High School/ Secondary
PREV. ACAD. REC.

School Examination
B. Sc.
M. Sc./M.A.
B. Tech./B.E.

Other (Pls specify)

#
Please provide e-mail mandatory not doing so may render your application incomplete.
M.Tech./M.Planning
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 Experience (From date to date) Designation Organization

EXPERIENCE
IF ANY

Payment details of application form

PAYMENT

(Rs. 400/- for General & Rs. 200/- Bank Draft No. Drawn on: Amount Rs.
SC/ST category)
Draft in favour of the Registrar, Date
MNIT Jaipur payable at Jaipur

Have you ever studied and discontinued your studies at MNIT, Jaipur YES NO
If YES, give particulars of the programme earlier attended and the reason for discontinuation
Names and addresses of two referees who are familiar with your academic background

Name Name
Address Address

PIN PIN
E-mail E-mail

UNDERTAKING
(1) I………………………………….S/o/D/o ………………………..state that I am aware that ragging in any
form in banned in MNIT, Jaipur and do hereby undertake not to indulge in any form of ragging during the
course of my study at MNIT, Jaipur
(2) Being a final year/semester student I also undertake to inform Academic Section, MNIT, Jaipur in writing that
if the requirements of my qualifying degree including Viva-Voce, if any, are not met by August 31, 2011.
Failure to inform the Head of Department about non-completion shall result in forfeiture of entire fees
deposited by me in addition to cancellation of admission.

Date....................... (Signature of the Candidate)

I am aware that ragging in any form is banned in MNIT, Jaipur and that I agree to abide by the punishment meted out
to my ward in case he/she is found guilty of ragging.

Date....................... (Signature of Parent/guardian)

FOR OFFICE USE ONLY

(Recommendations/observations of the office)
The candidate may be provisionally admitted/subject to the following/not admitted due to the following
production/non submission:
1. Production of attested copies of the qualifying degree certificate and marks sheet showing the required % of
marks/CGPA by 22-07-2011.
2. Production of proof from the University/Head of the Institution of having appeared/passed in the qualifying
Degree Examination by at the time of admission.
3. Production of relieving certificate from Employer by 22-07-2011.
4. Production of SC/ST/OBC/PH Certificate by 22-07-2011.
5. Production of Medical Certificate
6. Migration Certificate

AR (Academic) Officer Incharge (PG) Dean, Academic Affairs

M.Tech./M.Planning
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 CERTIFICATE OF MEDICAL FITNESS

The certificate must be from the Medical Officer or any rank above it from any
Central/State Government Hospital/Dispensary/Medical College must be brought by the candidate at
the time of interview.

1. Application Form No. : ……………………………………..

2. Name of the Candidate
3. Father's Name
4. Mother's Name
5. Sex
6. Height
7. Weight
8. Identification Mark
9. Chest Measurement
10. Heart and Lungs
Piles, Hydrocele,
Hernia etc.
11. Vision
12. Colour Blindness
13. Hearing
: ……………………………………..
: ……………………………………...
PHOTO
: .......................................................... (To be attested by the
: (Male/Female) Doctor signing the
Certificate)
: ……………………………………..
: ……………………………………..
: ……………………………………..
: ……………………………………..
: ……………………………………..
: ………………………………………..
: ………………………………………..
: ………………………………………..

Certified that the candidate possesses the medical standards given below and is medically fit for
the engineering profession.

Place: …………………………..

Date: ……………………………
Signature & Designation with seal of the
Authorised Medical Officer
________________________________________________________________________________
MEDICAL STANDARDS

Height: Not less than 1.5 m for male candidates and not less than 1.4 m for female candidates.
Weight: 41 kg. approximately for male candidates and 37 kg. approximately for female candidates.
Chest Measurement: Not less than 69 cm. with satisfactory limits of expansion and contraction for
male candidates only
Heart & Lungs: No abnormality.
Hernia, Hydrocele, Piles, etc.: Presence of any of these is a temporary disqualification to be rectified
before joining the course of study.
Vision: Normal. Where defective, it must be corrected to 6/9 in the better eye and 6/12 in the worse
eye. Eye should be free from congenital and other diseases.
Hearing: Normal. Where defective it must be corrected.

M.Tech./M.Planning
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Address for correspondence: (to be filled by the candidate)

Mr./Ms. …………………………………………
Father’s Name: …………………………………
Address……………………………………………
……………………………………………
…………………………. Pin …………
Contact Phone No. …………………………………………… Mobile No. ……………………………
E-mail: ……………………………………………………………………………………………………

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Mr./Ms. …………………………………………
Father’s Name: …………………………………
Address……………………………………………
……………………………………………
…………………………. Pin …………

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Mr./Ms. …………………………………………
Father’s Name : …………………………………
Address……………………………………………
……………………………………………
…………………………. Pin …………

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Mr./Ms. …………………………………………
Father’s Name : …………………………………
Address……………………………………………
……………………………………………
…………………………. Pin …………

M.Tech./M.Planning
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 Annexure 1

AUTHORITIES WHO MAY ISSUE CASTE/TRIBE CERTIFICATE

(SC/ST candidates should submit certificate issued by any of the following authorities)

District Magistrate/Additional District Magistrate/ Collector/ Deputy Commissioner/ Additional

Deputy Commissioner/ Deputy Collector/ 1st Class Stipendiary Magistrate/ City Magistrate/ Sub-
Divisional Magistrate / Taluka Magistrate /Executive Magistrate /Extra Assistant Commissioner/
Chief Presidency Magistrate/Additional Chief Presidency Magistrate/ Presidency Magistrate/
Revenue Officer not below the rank of Tehsildar/Sub-Divisional Officer of the area where the
candidate and /or his/her family normally resides/Administrator/Secretary to
Administrator/Development Officer (Lakshadweep Island).
(Certificate issued by any other authority will be rejected.)

Annexure 2
CERTIFICATE FROM INSTITUTE / UNIVERSITY
(Required during registration from candidates whose result of the qualifying examination has not
been declared)

I hereby certify that Mr./Ms. ............................................... has appeared in the final year
examination including theory, practical and project examination for
B.E./B.Tech./B.Sc./M.Sc.………………………….degree (strike out the non-applicable ones and
write in the blank if the degree is not mentioned) and the result is likely to be announced by
......................………….......... 2011. His/her conduct and character during his/her stay at the
Institute/University was “GOOD”.

Place: ................... Signature of the Principal/Dean/Registrar/

Date:…................ Dy. Registrar/Proctor/Administrative
Officer of the institute last attended with seal

Annexure 3

CERTIFICATE OF THE FORWARDING OFFICER

(Required from candidates who is yet to appear in the qualifying examination or yet to get the
degree)

I hereby certify in connection with the application of Mr./Ms. ............................................... that he/
she is a bonafide student of our institution and is applying for admission to PG programmes at
MNIT Jaipur. He/She is yet to complete / has completed all the requirements of qualifying
examination including theory, practical and project examination for B.E./B.Tech./B.Sc./M.Sc.
…………………….. (Strike out the non-applicable ones and write in the blank if the degree is not
mentioned) and the result is likely to be announced by ................................ 2011. His/her conduct
and character during his/her stay at the Institute/University is “GOOD”.

Place:................ Signature of the Principal/Dean/Registrar/

Date:................. Dy. Registrar/Proctor/Administrative Officer
of the institute attending/last attended with seal

M.Tech./M.Planning
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 Annexure 4
NO OBJECTION CERTIFICATE
(Required from Candidates Seeking Admission on Part-time Basis)
(On a letterhead of the sponsoring organization & enclosed with application for admission)
The undersigned is pleased to permit Mr./Ms. ................................................. who is working in this
organization for the last ..............…………………….. years and is presently holding the
rank/position of ................................................. for pursuing the programme (course) at MNIT,
Jaipur in the Department of ………………………………………............................. with
specialization in the following areas:
1.......................................
2…...................................
3. …….…………………
His/her conduct and character is good. We are ready to release him/her during working hours to
undergo the programme as per MNIT, Jaipur time-table. We understand that the duration for part
time M.Tech. is expected to be 3 years.
It is noted that normal instructional hours are from 8.00 a.m. to 5.00 p.m. and also some courses may
be held in extra time slots. We shall bear the total expenses of his/her studies.

Place: .................. Signature of Head of the Institution/Organization with seal

Date:.................... Name.................................................................
Designation ..................................................

M.Tech./M.Planning
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