MOTHER THERESA INSTITUTE OF ENGINEERING AND TECHNOLOGY

(Approved by AICTE, Affiliated to JNT University, Anantapur) Melumoi (Post), Palamaner-517408, Chittoor-District, A.P
Affix Pass port

BRANCH:
1. NAME OF THE CANDIDATE (CAPITALS, As per SSC) 2. SEX (please ) 3. BLOOD GROUP (Attach Lab Certificate) 4. NAME OF THE MOTHER 5. NAME OF THE FATHER/GUARDIAN 6. OCCUPATION & ANNUAL INCOME OF THE PARENT/GUARDIAN 7. DATE OF BIRTH 8. ADDRESS FOR COMMUNICATION

EAMCET CODE: M T I E
: ______________________________________ ______________________________________ : MALE / FEMALE

Size Photograph

: ___________________________________________________ : _____________________________________________________ : _____________________________________________________ : _____________________________________________________ : _____________________________________________________ : _____________________________________________________ _____________________________________________________ ___________________________Pin:_______________________

9. TELEPHONE NO. (With STD code)

: _____________________________________________________

10. MOBILE NUMBER-1: __________________________ MOBILE NUMBER-2: ____________________________ 11. EMAIL ID 12. PERMANENT ADDRESS : _____________________________________________________ : _____________________________________________________ ____________________________________________________ __________________________Pin:_______________________ YEAR OF PASSING % of MARKS RANK IN EAMCET

13. DETAILS OF QUALIFYING EXAMINATION: (10+2) GROUP MEDIUM or Equivalent

14. NAME OF THE COLLEGE LAST STUDIED 15. RELIGION

: _____________________________________________________ : _____________________________________________________

16. CATEGORY [OC][SC/ST][BC-A/B/C/D][MINORITY]: ________________________________________________ 17. SUB - CASTE 18. WHETHER ELIGIBLE FOR ANY SCHOLARSHIPS (please ) 19. CATEGORY OF ADMISSION (please ) 20. REGION (please ) 21. COLLEGE ROLL NO. (Office use) : ____________________________________________________ : YES / NO

: EAMCET Counseling / NRI / MANAGEMENT : SVU ( ) AU ( ) OU ( )

: _____________________________________________________

22. IDENTIFICATION MARKS (AS PER SSC)

: _____________________________________________________ : _____________________________________________________

22. OTHER PARTICULARS, IF ANY

:____________________________________________________

JOINT UNDERTAKING BY THE APPLICANT AND PARENT / GUARDIAN

1. The information furnished herein is true and correct to the best of our knowledge. In

case any

information furnished is found incorrect, we agree to forego any claim for admission / are found to be false at a later date on verification, I / my son / daughter will forfeit the admission / seat, no matter at what stage of the course /class at that time. 2. We promise to abide by all the rules and regulations of your College / Society 3. We agree that any amount paid to the institution is non-refundable after admission. We undertake that we will not claim refund of the fees etc. paid already under any circumstances. 4. We agree that if my son / daughter wishes to leave the institution in the middle, we will pay the fee for the full course (all the 4 years) before the issue of the Transfer Certificate and other Certificates. 5. Further we both (Student & Parent) undertake that we will not insist for the refund of fees etc., paid to the institution at the time of admission on account of any reason.

STATION: MELUMOI (POST), PALAMANER.

Signature of the student

Date:

Signature of the Father / Guardian

LIST OF ENCLOSURES: (2 sets of Xerox copies to be attached with the application)

1. 2. 3. 4. 5. 6. 7. 8.

SSC Marks Sheet Intermediate Marks Sheet Provisional Certificate Diploma / Degree Marks Sheets Community Certificate Transfer Certificate Migration Certificate

: : : : : : :

YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO

Passport size Photo 4 Nos. : (Both mother & father 2 passport size photos) Study Certificate from1std to Intermediate EAMCET / ECET Rank Card Caste Certificate Income Certificate Blood Group Certificate : : : : :

9. 10. 11. 12. 13.

YES / NO YES / NO YES / NO YES / NO YES / NO

Note: Original Certificates must be surrendered at the time of admission.

FOR OFFICE USE ONLY

Application Complete: YES NO

If NO tick the relevant item in the list of defects given below.

No. of appearance is more.

Not obtained minimum marks in the Qualifying Examination No proper community certificate

Not satisfied with Andhra Pradesh Nativity Over aged Not passed the prescribed qualifying Examination Not applicable for Special Category

The candidate is eligible / not eligible...................................................................................................... (If not eligible, specify the reason)

Branch allotted.............................................................................................................................................

PRINCIPAL

ANNEXURE I AFFIDAVIT BY THE STUDENT

I, _______________________________ s/o, d/o

Mr./Mrs./Ms.__________________________,

having been admitted to ______________________________, have received a copy of UGC Regulations on Curbing the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the Regulations) carefully read and fully understood the Provisions contained in the said Regulations.
1) I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging. 2) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against me in case I am found guilty of or abetting ragging, actively or passively, or being part of conspiracy to promote ragging. 3) I hereby solemnly aver and undertake that a) I will not indulge in any behavior or act that may be constituted as ragging under clause 3 of the Regulations. b) I will not participate in or abet or propagate through any act of commission or omission that may be constituted that may be constituted as ragging under clause 3 of the Regulations. 4) I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against me under any penal law or any law for the time being in force. 5) I hereby that I have not been expelled or debarred from admission in any institution in the country on account of being found guilty of , abetting or being part of a conspiracy to promote, ragging: and further affirm that, in case the declaration is found to be untrue, I am aware that my admission is liable to be cancelled. Declared on _______________________________. Signature of the deponent Name:

VERIFICATION Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit is false and nothing has been concealed or misstated there in. Verified at ____________ on ______________________ Signature of the deponent Solemnly affirmed and signed in my presence on ___________ after reading the contents of this affidavit.

Oath Commissioner

ANNEXURE II AFFIDAVIT BY PARENT / GUARDIAN

I, _______________________________ F/O, M/O

Mr./Mrs./Ms._________________________,

having been admitted to ______________________________, have received a copy of UGC Regulations on Curbing the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the Regulations) carefully read and fully understood the Provisions contained in the said Regulations.
1) I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging. 2) I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against me in case I am found guilty of or abetting ragging, actively or passively, or being part of conspiracy to promote ragging. 3) I hereby solemnly aver and undertake that c) I will not indulge in any behavior or act that may be constituted as ragging under clause 3 of the Regulations. d) I will not participate in or abet or propagate through any act of commission or omission that may be constituted that may be constituted as ragging under clause 3 of the Regulations. 4) I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against me under any penal law or any law for the time being in force. 5) I hereby that I have not been expelled or debarred from admission in any institution in the country on account of being found guilty of , abetting or being part of a conspiracy to promote, ragging: and further affirm that, in case the declaration is found to be untrue, I am aware that my admission is liable to be cancelled. Declared on _______________________________.

Signature of the deponent Name: Address: Telephone/Mobile No: VERIFICATION Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit is false and nothing has been concealed or misstated there in.

Verified at ____________ on ______________________ Signature of the deponent Solemnly affirmed and signed in my presence on ___________ after reading the contents of this affidavit.

Oath Commissioner