GURU NANAK DEV ENGINEERING COLLEGE

BIDAR – 585 403. (Karnataka)

(Affiliated to Visvesvaraya Technological University and Approved

by AICTE)
Accredited By National Board of Accreditation (NBA)
Application for Admission to First year / Second year (Lateral Entry)
Of Four year Degree Course in Engineering

Reg. No……………………….
Affix Recent
(To be filled in by the office)
Passport Size
Photograph
College Roll No………………
(To be filled in the office)

A-PERSONAL INFORMATION OF CANDIDATE

1. Name of the Applicant (in block letters)

as given in the qualifying examination
certificate. Surname should be
underlined
2. Permanent Home Address & Tel. No.
With STD CODE
3 Present address for Correspondence &
Telephone
No. (Inform the Principal immediately of
any
change in the Address & Telephone No.)
4. Date of Birth
5. Nationality of the Candidate
6. Identification Marks
7. Sex Male/Female
8. Religion
9. Caste
10. Do you belong to SC/ST/OBC
(A certificate as a proof is essential)
11 Marital Status Married/Unmarried
12. Languages known
 (a)
13. Hobbies & Extra Co-Curricular Activities (b)
(Give Proof) (c)
(d)

B-Personal Information of Parent/Guardian

1. Father's Name
2. Mother's Name
a) Name:
3. Guardian (if parents are not alive)
b) Relationship:
4. Address of Parent Guardian and Telephone
No. if any
a) Father:
5. Educational Qualification of Parents
b) Mother:
6. Occupation of Parent with Designation
7. Annual Income of Parent/Guardian from all
sources
C-Documents of Candidate
1. Documents to be submitted by Candidate
a) Admission from duly filled in ( )
b) 10+2 Marks Statement ( )
c) Date of birth (Matriculation Certificate) ( )
d) Transfer/Leaving Certificate ( )
e) Migration Certificate ( )
f) Religion Certificate (For Sikh) ( )
g) Any Other (Specify) ( )
2. To which state do you belong (in case you
belong to Karnataka State Produce Domicile
Certificate by an Officer of the Rank of
Deputy
Commissioner)
D-EDUCATIONAL RECORD : 1) Details regarding qualifying examination
Name No. of
Exam
Name of the of the Duration of Attemp Year of
Passe Reg. No.
College Univ. Course ts Passing
d
/Board Made

2. Have you passed English in the qualifying examination Yes/No

3. Details of Marks in qualifying examination
a) (To be Filled by Candidate Passing 10+2)
%age of Marks scored
Subject Marks Secured Maximum Marks
(upto 2-decimal digits)
i) PHYSICS
ii) MATHEMATICS
iii) Any one of
Following
CHEMISTRY
BIOLOGY BIO-
TECHNOLOGY
COMPUTER SC.
ELECTRONICS
TOTAL:
b) To be filled by Diploma Pass Candidate
Max. Marks of
Marks obtained in Percentage Aggregate of
Diploma IIIrd
Diploma IIIrd year Marks Scored
year
DIPLOMA IN ……
……………………
TOTAL
6. Branch of Engineering desired in order of preference (the branch will be allotted at
the discretion of the Chairman subject to availability. No change will be permitted later
at any stage)
1)
2)
3)
4)
5)
E-Medical Details of Candidate (To be billed in by the parents)
1. In case of Emergency whom to
Contact
a) Name
b) Telephone No. with STD Code
2. Blood Group of Candidate
3. Allergy to any Medicine
4. Past Medical History of Candidate (To
be
filled in by the Parents)
Information provided by you will be the basis of providing further Medical treatment to
your ward please write your ward's complete Medical History for our records.
STUDENTS IN THE HABIT OF SMOKING CONSUMING LIQUOR OR UN-AUTHORISED DRUGS
NEED NOT APPLY

Signature of the Parent/Guardian

Office Note
(To be filled by the Office)
R. No………….Date:………Rs………
1. Receipt No. & Date of Sale of
Application Form
Signature
2. Date of Receipt of the Complete
Application Form
3. Student has Passed/Not Passed in
the Eligible / Not Eligible
Qualifying Examinations
4. Whether Admitted Yes/No
5. Fees Paid
Amount Receipt No. Date Signature of Dealing official

6. College Roll Number Allotted

7. Branch Allotted

Signature of Dealing Official

AFFIRMATION OF CANDIDATES
1) I do hereby certify that the particulars furnished above are correct.
2) I hereby agree, if admitted, to abide by the Rules & Regulations of the
College in force from time to time including the dress code as given in
the prospectus.
3) I undertake that I will do nothing inside and outside the College that will
interfere with the orderly management and discipline.
4) I will do nothing which will bring a bad name to the College or the
management in any way.
5) I will not consume liquor or drugs (not prescribed by the Doctor) in the Hostel
or College, I shall not smoke in the College and Hostel premises.
6) I will not indulge in any ragging activities during my course of study
in the College. If found guilty the management can expel me from
the College.
7) I will not interfere in the policy matters of the management relating
to administrative affairs during my course of studies in the College.
8) I shall treat the Attendance in the morning assembly/period meant for
Students activates Co-Ordination committee / Sports / Any function /
activities organized by the College as part of my curricular activities and will
attend the same.
9) I further agree to submit to any action may entail cancellation of admission
rustication / expulsion and/or criminal prosecution (if necessary as per law)
10)I fully understand that above action may entail cancellation of admission
rustication / expulsion and/or criminal prosecution (if necessary as per law)
11) I fully understand that I have been given admission as Sikh student under
minority quota and that in case, I fail to maintain the Sikh status I am liable
to disciplinary action of expulsion / confiscation of security deposit from the
College (Sikh Students).
12) I understand that Branch of Engineering Allotted by Management will be final.
13)I have read and understood the above clauses and hereby append my
signature by my own free will.

Date: Signature of the Candidate

Place:
 AFFIRMATION OF PARENT / GUARDIAN
1) I certify that the above particulars furnished by my son / ward are correct.
2) I undertake to educate my son/ward in this college till completion of the course.
3) I undertake the responsibility of timely payment of all college dues of my
son/ward and for his good conduct throughout his stay in the college. In case of
failure to do so the Management's decision will be final and binding on me.
4) I understand that failure to clear the College dues before University Examination
my ward will not be permitted to appear in the examination.
5) In case I withdraw my son/ward in the middle of the course, I agree to pay
remaining year fees compensation stipulated by the management of
the College.
6) I understand that the admission once taken is final and amounts paid
shall not be refunded under any circumstances.
7) I understand that in case of false / suppressed information my son/ward is likely
to be expelled from college in addition to criminal prosecution if required.
8) I understand that my ward shall be expelled/rusticated if found consuming
liquor, or un-authorized drugs or smoking.
9) I have fully understood the consequences of the above undertaking and hereby
append my signature by my own free will.
10)Any legal dispute will be subject to Bidar Jurisdiction.

Date: Signature of the

Parent/Guardian

Place