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Application form for VITEEE - 2015 Full Name : JYOTIRMOYEE DAS Application. No. : 2015117870 Date of Birth : 01/08/1996 Gender : FEMALE Religion : Hinduism Nationality : Indian Community : General/OC Mother Tongue : Bengali Native State : West Bengal Mode of Study : Regular Landline No. : 033 - 65641828 Mobile No. : 9836435878 Parent name : DHURJATI DAS Hostel : Yes Choice of Campus : Vellore Email ID. : jyotirmoyee.das10@gmail.com Qualifying Exam : 12th Class Month & Year Passing : Mar - 2015 Exam Roll.No./Reg.No. : Testcity : KOLKATA Permanent Address : NIRMALA APARTMENT, GUPTA COLONY NABAPALLY,BARASAT,BARASAT, KOLKATA,NORTH 24 PARGANAS,WEST BENGAL,700126. Name of the School : KALYANI PUBLIC SCHOOL Address of the School : NOAPARA,MOINAGADI, BARASAT, KOLKATA, NORTH 24 PARGANAS,WEST BENGAL, 700125. 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 of Equipercentile Equating in particular. I accept this method to be adopted for Merit List preparation by VIT. Date : Place : Signature of Parent / Guardian Signature of the Applicant Details of Demand Draft: Bank Name : State Bank of India DD No. : 756952 DD Date : 22-Jan-2015 DD Amount : 940 Note : 1.It is mandatory that the candidate should send the hardcopy of the application form to the address of the Director - UG Admissions, VIT University, Vellore -632014,Tamil Nadu. 2.Candidate should retain the photocopy of the Application form. 3.Candidate must write their application no. and name and mobile no. on the reverse side of the DD.

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