Bhilai Institute of Technology, Raipur (Seth Balkrishan Memorial) Inspiring generaon Inspiring Technology [Approved by AICTE, New Delhi, Affiliated to CSVTU Bhilai. Consented by CG Govt.] APPLICATION FORM B.E. M.Tech. DIPLOMA B.E. PROGRAMMES OFFERED 60 SEATS M. Tech DIPLOMA COURSE POST GRADUATION COURSE UNDER GRADUATE COURSES (ENGINEERING) 18 SEATS 30 SEATS 30 SEATS DIPLOMA IN EEE DIPLOMA IN MECHANICAL ENGINEERING MECHANICAL ENGINEERING COMPUTER SCIENCE CIVIL ENGINEERING 60 SEATS 120 SEATS ELECTRONICS & TEL. COMM. ENGG 60 SEATS 60 SEATS ELE. & ELECTRONICS ENGINEERING INDUSTRIAL SAFETY
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B.E. M. Tech · 3. PET/JEE Marksheet - 2 photocopies 4. 10th & 12th Marksheets - 4 photocopies 5. Original Migraon Cerficate + 2 photocopies (Only for CBSE students and Other Board
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Bhilai Institute of Technology, Raipur(Seth Balkrishan Memorial)
Inspiring genera�on Inspiring Technology[Approved by AICTE, New Delhi, Affiliated to CSVTU Bhilai. Consented by CG Govt.]
APPLICATION FORM
B.E.
M.Tech.
DIPLOMA
B.E.
PROGRAMMES OFFERED
60SEATS
M. TechDIPLOMA COURSE
POST GRADUATION COURSE
UNDER GRADUATE COURSES (ENGINEERING)
18SEATS
30SEATS
30SEATS
DIPLOMAIN EEE
DIPLOMA INMECHANICALENGINEERING
MECHANICALENGINEERING
COMPUTERSCIENCE
CIVILENGINEERING
60SEATS
120SEATS
ELECTRONICS &TEL. COMM. ENGG
60SEATS
60SEATS
ELE. & ELECTRONICSENGINEERING
INDUSTRIAL SAFETY
Bhilai Institute of Technology, Raipur
COURSE AND BRANCH : __________________________________________________
1. Name of the Candidate : __________________________________________________
(As men�oned in the qualifying
examina�on cer�ficate)
2. Date of Birth :
3. Gender : Male Female
4. Blood Group : __________________________________________________
Phone : ______________________________ Phone : __________________________ with STD Code with STD Code
(Seth Balkrishan Memorial)
15. Hostel Accomoda�on : Required Not Required
16. Details of Qualifying Entrance Examina�on :
Entrance Name Roll No. Category Rank Overall Rank Marks Obtained
17. Marks obtained in the Board Examina�on
Exam Board/University School / College Name Year %
SSC
HSSC
DECLARATION OF THE CANDIDATE
• I Solemnly affirm that I have gone through the prospectus of the “Ins�tute Containing” the rules and regula�on.
• I undertake that I shall not par�cipate in any kind of demonstra�on/agita�on/strike etc.
• I hereby undertake that I will neither get involved in ac�vites directly or indirectly nor cause any sort of mental physical harassment to my juniors. The informa�on provided by me in this applica�on form are true and correct to the best of my knowledge.
• I am fully aware of the rule that once admi�ed to the ins�tute, annual fee is not refundable in any circumstances and I shall have no claim on it except on cau�on deposit.
• In case any infora�on/cer�ficate at any stage is found incorrect, my Admission may be cancelled without no�ce and I will not have any claim for the loss whatsoever it may be.
_____________________________ Father/Gaurdian’s SignatureName : Place :Date :
_____________________________Candidate’s Signature Name : Place :Date :
FOR OFFICE USE ONLY
Payment Type Amount MR. No. with Date
Prof. Incharge Admission Account Officer Principal
1. Original and photocopies of counselling allotment - 2 copies
2. DVC Form - 1 copy
3. PET/JEE Marksheet - 2 photocopies
4. 10th & 12th Marksheets - 4 photocopies
5. Original Migra�on Cer�ficate + 2 photocopies (Only for CBSE students and Other Board students)
6. Original Transfer Cer�ficate + 2 photocopies
LIST OF ENCLOSURES7. If any gap is there (from 12th passing to as on date) Original Gap Cer�ficate + 2 photocopies
8. Colour Passport Photographs - 12 photos
9. Domicile & Caste Cer�ficate - 2 photocopies10. Parents Current Year Income Cer�ficate - 2 photocopies
11. Aadhar Card - 2 photocopies
Address : Near Kendri Rly. Stn., Abhanpur Road, Atal Nagar (Naya Raipur) Dist.- Raipur 493 661 (C.G.) INDIA
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