GOVERNMENT POLYTECHNIC, MURTIZAPUR
DEPARTMENT OF INFORMATION TECHNOLOGY
STUDENTS MENTORING SYSTEM
A) Personal Information
1. Name of Student :_________________________________________ Recent
2. Enrollment number : _________________________________________ Passport
3. Year of Admission : _________________________________________
Photo
4. Branch Name : _________________________________________
5. Date of Birth : _________________________________________
6. Blood group : ____________________ Gender : Male / Female
7. Contact No. : Personal: ___________ Father/Mother: __________________
Local Guardian (if any): _________________________________________
8. E-mail Id. : _________________________________________
9. Aadhar No. : _________________________________________
10. Bank Details : A/c No.: __________________ Bank Name: ___________________
Branch Name:________________ IFSC Code: ___________________
11. Address :
• Permanent Address : _________________________________________
• Local Address : _________________________________________
12. Details of siblings:
Name Brother& Sister Contact Details Academic status
13. Medical Fitness: Details of diseases if any
______________________________________________________________________________
14. Problems/difficulty faced by student:
(Personal/Academic/Medical/Any other)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
15. Details of Academic performance:
Class/Semester First % Marks Backlog Subjects(if any) Passed in
Appeared in
(W/S Year)
(W/S Year)
16. Participation in CO- circular Activities:
Event Participation Type Achievement Participation Year
17. Participation in Extra-Curricular Activities:
Event Participation Type Achievement Participation Year
B) Details of Mentoring
Name of Mentor: _____________________________________ Mentor Mobile No: _______________
Strength of Students:
Weakness of Student:
Date Topic Mentor’s Remarks Student
Signature
Observation of Mentor (if Any) ___________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Action taken by Mentor _________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
If applicable Action taken by HOD ________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Principal______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Weather problem faced by Mentee resolved or not:__________________________
(Student Sign)
Details of Internships
Sr. Semester Name of Industry Duration
No.
Title of Final Year of Project
Placement /Higher studies (if any)
Academic Year 20 - 20 20 - 20 20 - 20
Term 1st 2nd 3rd 4th 5th 6th
Semester Semester Semester Semester Semester Semester
Mentors Signature
HODs Signature
