Approved By AICTE New Delhi & Govt.
of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net
REGISTRATION FORM (B.E.) 2016 - 2017
Date of Registration …………………
Domicile:- M.P. / AI Category:- ( Gen / OBC / SC / ST )
Recent
passport
12th Roll No. ……………..……….… 12th %:- ……..… 12th PCM% .............
photograph
Name of Board: ……………………………….. Year of Passing- ……….…
JEE Roll No. …………………………. JEE Marks …………
1. Student Name [In Capital]:-
First Name Middle Surname
2. Father’s Name:-
3. Mother’s Name:-
4. Gender.: Male Female
5. Date of Birth: Date Month Year
6. E-mail I.D. ……………………………………………………………………………….
7. Permanent Address:- ……………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
8. Present Address:- ………………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
Candidate Mob. No.1
Guardian Mob. No.2
(Contd……)
Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net
REGISTRATION FORM 2016
LATERAL ENTRY
Name of Institute: _________________________________________
Affix
Course: B.E. / B. Pharm recent
Branch:- ( EC / CS / IT / ME / EX / Civil) Photo
Domicile:- M.P. / AI Category:- ( Gen / OBC / SC / ST )
Diploma/B.Sc. Roll No.:………………… Diploma/B.Sc. Marks ……………
Diploma/B.Sc.: Theory % , ……………… Aggregate %………………
1. Student Name [In Capital]:-
First Name Middle Surname
2. Father’s Name:-
3. Mother’s Name:-
4. Gender.: Male Female
5. Date of Birth: Date Month Year
6. E-mail I.D. ……………………………………………………………………………
7. Permanent Address:- ……………………………………………………………….
………………………………………………………………………………………..
……………………………………………………… Pin Code
8. Present Address:- ……………………………………………………………………
………………………………………………………………………………………...
……………………………………………………… Pin Code
Candidate Mob. No.1
Guardian Mob. No.2
(Contd……)
Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net
REGISTRATION FORM (MCA) 2016 - 2017
Date: ………………………..
Name of the Institute (to which registered): …………………………………
Recent
Domicile:- M.P. / AI Category:- ( Gen / OBC / SC / ST ) passport
photograph
Maths at 12th Graduation
Graduation in : ………….……….. % ……..…… Year of Passing- …………
Pre-MCA Roll No. ……………………. Pre-MCA Marks …………………..
1. Student Name [In Capital]:-
First Name Middle Surname
2. Father’s Name:-
3. Mother’s Name:-
4. Gender.: Male Female
5. Date of Birth: Date Month Year
6. E-mail I.D. ……………………………………………………………………………….
7. Permanent Address:- ……………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
8. Present Address:- ………………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
Candidate Mob. No.1
Guardian Mob. No.2
(Contd……)
Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net
REGISTRATION FORM (MBA) 2016 - 2017
Date of Registration …………….………
Name of the Institute (to which registered): ………………………………… Recent
passport
Domicile:- MP / AI Category:- ( Gen / OBC / SC / ST ) photograph
CMET Roll No.:-……………………… CMET Marks: ………….…………..
SN. Name of Course/ Name of Institute Board/ Univ. Year of % Enroll. No.
Examination Stream Passing
1 10th
2 12th
3 UG
4 PG
1. Student Name [In Capital]:-
First Name Middle Surname
2. Father’s Name:-
3. Mother’s Name:-
4. Gender.: Male Female
5. Date of Birth: Date Month Year
6. E-mail I.D. ……………………………………………………………………………….
7. Permanent Address:- ……………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
8. Present Address:- ………………………………………………………………….……
………………………………………………………………………………………...…..
……………………………………………………… Pin Code
Candidate Mob. No.1
Guardian Mob. No.2
(Contd……)
Approved By AICTE New Delhi & Govt. of Madhya Pradesh
Affiliated To Rajeev Gandhi Proudyogiki Vishwavidyalaya, Bhopal
Anand Nagar, P.B. No. 24, Post Piplani, BHEL, Bhopal-462021
Ph. No.- 2685977, 2751693, 2713736 Fax- 0755-2751679 E-mail: titbhopal@gmail.com, www.titbhopal.net
REGISTRATION FORM SESSION 2016-2017
M.E. / M.Tech
Recent Passport
Photo with Sign.
Name of the Deptt. Branch
First Name Middle Name Surname
1. Name
(Block letters)
2. Father’s Name ______________________________________________________________
3. Mother’s Name ______________________________________________________________
4. Gate/Non Gate/Sponsored __________________________ 5. Gate Percentile __________________
6. Name of Qualifying Examination (BE/B.Tech/MCA) ____________________%________________
7. Category (Gen/SC/ST/OBC/Disabled) ________________ 8. Sex (Female/Male) _______________
9. Date of Birth __________________________ 10. Nationality _______________________
11. Religion: …………………..…... 12. Caste: ……………………………………………...
13. Whether Belongs to Economical Backward Class: Yes No
(If yes, enclose it’s support)
14. Permanent Address:- ………………………………………………………………………….……
.………………………………………………………… Pin Code
15. Present Address:- ………………………………………………………………………….……
.………………………………………………………… Pin Code
Candidate Mob. No.1
Guardian Mob. No.2
16. Qualification (Starting from 10+2 till date):-
SN. Name of Subject / Board/Name of the Year of Percentage of Remarks Encl.
Examination Branch Institution/University Passing Marks & Division No.
1 10th
2 12th
3 BE/B.Tech/MCA
(Contd……)
