DEPARTMENTAL ADMISSION FORM (Candidate is required to write correct information in their own handwriting)

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1 The Shirpur Education Society s R. C. Patel Institute of Technology, Shirpur High Caliber Technical Education in an Environment that Promotes Excellence Paste Your Pass-Port size Photo graph here & attach 2 extra photo Form UNIVERSITY PRN Student should sign strictly inside of the box given beside only with black ink pen DEPARTMENTAL ADMISSION FORM (Candidate is required to write correct information in their own handwriting) Name of Candidate: (In BLOCK LETTERS as appeared on your SSC Marksheet) Course: Bachelor of Engineering (BE) / Master of Technology Management (MTM) Year: Second Year (through FE) / Direct Second Year (D2D) Third Year (TE) / Final Year (BE) Branch: Computer Engineering Information Technology Electronics & Telecomm. Engg Shift I Mechanical Engineering Shift I Civil Engineering Electronics & Telecomm. Engg Shift II Mechanical Engineering Shift II Electrical Engineering Whether admitted in Tuition Fee Waivers Scheme (TFWS)? Yes / No First Year/D2D Admission Year to this Institute : 20 / 20 (Write the year when you admitted to this institute first time) Whether you are a regular student during last year: Yes / No If no, state the year when you were admitted previous year as a regular student: 20 /20 Fee concession claimed: SWO / EBC / TFWS / PH Scholarship Category for fee claimed: Academic Fee Details Fee By Student By Govt. By Mgt Concession Total Fee in Rs. Previous Year Current Year Name of Local Guardian: Signature.: Signature of HOD: Signature of Principal: RCPIT Regular Admission Form

2 Personal Details 1. Name of Candidate : (In BLOCK LETTERS as appeared in your SSC Marksheet) (Surname) (First Name) (Middle Name) 2. Male / Female : 3. Marital Status: Married / Unmarried 4. Nationality : Domicile: 5. Date of Birth (DD/MM/YY)(As per your TC/LC) : Blood Group: 6. Birth place details: Village/Town State 7. Religion: 8. Caste as per your last LC: (Applicable for candidates admitted through CAP and belonging to Maharashtra State only) 9. Height (Cms) : 10. Weight (Kgs) : 11. Whether Physically Handicapped?: Yes / No 12. Mother Tongue 13. Whether ward of Defense Service Personnel?: Yes / No 14. Details Permanent Communication Line Town/City Taluka / Tehsil Pin Code State Phone ( ) ( ) Mobile ID Adhar Card No. 18. Other details of Candidate How many Brothers / Sisters? Brothers Elder Younger Sisters Elder Younger Hobbies, Proficiency and other Interest Name of Games and Sports / Cultural Activity participated before. Personal identification Marks (if any) Major illness/operation issues (if any) Family Type (please tick) Combined Isolated Do you stay in Hostel? Yes No If you are not a hotelier then write residential address of Shirpur RCPIT Regular Admission Form

3 Academics & Qualifying Exam Standard / Class (Write 10 th /11 th /12 th /Diploma 1 st /Diploma 2 nd / Diploma 3 rd / FE/SE/TE) If any GAP in between, what you have done? Details of Previous Examination and College Name of School / College City of School / College Pin Tal State Year of Passing Sem - I Sem - II Total Aggregate Marks (Sem I & II) Examination Seat Marks obtained Marks obtained Total Marks obtained Mark Statement (printed on Annual Mark sheet) / / / / / / / / / / / / Aggregate % of Marks % % % % Details of Awards & Rewards / Achievements received in previous years Details of Paper / Project Presentation / Workshop / Seminar /Industrial Training attended (if any) [Attach separate sheet if necessary] Any Programming Languages known? Whether you required academic and campus assistance from the Institute? Industrial Training Technical Training Soft Skill Training Placement Assistance Higher Education Assistance GRE / TOEFFL / GATE / CAT or Other Whether you required any assistance for extra-curricular activity from the Institute? Have you passed any Qualifying / Foreign Exam for Higher Education? (Please Specify) Sports Cultural Name of Sports Type RCPIT Regular Admission Form

4 Parents Information Father Mother Name in Full (Surname, First Name, Middle Name) Age (in years) Qualification (Please tick any one) Occupation Up to 12th UG PG Up to 12th UG PG Professional Degree Professional Degree (Write as Private Service/Business/Farmer/Laborer/Retired/Govt. Service/Doctor/Advocate/Teacher/Professor/House-wife etc) Name of Office Office City Pin Taluka State Phone with STD Code Designation Mobile No. PAN Card Your relative who is the employee of company/industry (if any) (this will help our students for placement/educational tour/training ) Name of Relative Company Name & Contact of your relative Designation/Post Your Opinion about us Please give marks out of 10. (10 is Max marks; 0 is min Mark) Marks out of 10 Marks out of 10 Teaching Methodology and Faculty Training and Placement Activity Campus and Infrastructure Extra-Curricular Activity University Results Students Facilities Brand Image and Management How do you rank this institute in North Maharashtra Region? 1 st / 2 nd / 3 rd RCPIT Regular Admission Form

5 Scholarships / Freeships (For the students who are beneficiary of Govt. Scholarship / Freeship in previous years i.e. For Category Scholarship / EBC / Minority Scholarship holders only) Religion: HINDU / MUSLIM / SIKH / CHRISTIAN / JAIN / PARSI Caste: OBC / SC / ST / NT-VJ-DT / SBC / OPEN (General) Sub-Caste: Type of Scholarship / Free-ship Holding in previous Year (Pls tick any one) Social/Tribal Welfare Scholarship (Category Concession) Economic Backward Class Concession (EBC) Minority Scholarship (Muslim/Jain/Sikh/Christian/Parsi) Student Nationalized Bank A/C Details Nationalized Bank Name Nationalized Bank Branch IFSC Code MICR Code Nationalized Bank Account Adhar Card Parents Annual Income for last three year Parents Income Certificate for (Issued by Megistrate/Tahsildar) Rs. /year March 2014 Rs. /year March 2013 Rs. /year March 2012 Date Issued by (Name of Tahsil) Caste related details (For the Student belonging to SWO Category Concession) Caste Certificate details Issuing officer Caste Validity details Issuing officer Taluka Issuing officer Scrutiny Committee Documents to be submitted with the application to be made for all above Concession Category Concession for OBC/SC/ST/NT-VJ-DT/ SBC EBC Minority List of Documents (All Xerox Copies) Schedule/Period of submitting application With your admission. Form, SSC marksheet, Last three years Marksheet, Caste Certificate, Submit before Caste Validity, Parents last year income certificate, Non-Creamy layervalid upto 2014, Domicile, Adhar Card, Bank passbook, Affidavit confirming your admission Form, Parents last year original income certificate, domicile, ration card, LC/TC, Last Year Marksheet, Fee Receipt, Dena Bank passbook, After Office Notification Adhar Card Online form, Parents last year income certificate, Affidavit, Domicile, After Office Notification Last Year Marksheet, Bank passbook, Adhar Card RCPIT Regular Admission Form

6 Declaration & Undertaking I have read all the instruction stated in Admission Information Booklet of DTE Mumbai at the time of my first admission and I agree to abide by the same. I understand rules and regulations of this institute and I agree to abide by the same. If I am found guilty in Ragging, I shall be punished as per the AICTE/UGC/State Govt. Act. I also understand that my admission is subject to the minimum 75% attendance in class/practical, term work submission and the work/assignment given by the concerned HOD/Principal from time to time. I further hereby declare that all the statements mentioned and data provided above are true to the best of my knowledge and belief. In the event of any particulars mentioned above being found false, suitable actions against me may be taken. Student Parents /Guardian Name: Signature: Name: Signature: Date: Date: For Office use only Information Verification Signatures Departmental Document Verification Check List of Documents Last Three Marksheet- (Xerox attached) Check date of birth as per LC/TC/any relevant doc Check Receipt of Stationery Check Receipt of Fee Check Installment Form (in case of part payment) Check whether he/she has submitted SWO Scholarship Form --- Check I-card Status Submit Anti Ragging undertaking Check previous year dues (if any) (Library/T&P/Fee/Dept. Breakage/ Sports/Cultural etc) Data Entry The data regarding the admission has been entered into Institute Admission Software. Name: Clerk Accounts Fee applicable: Fees Paid: Receipt : Due Date if any HOD and local Guardian Division: Roll : Name of Local Guardian and Sign: RCPIT Regular Admission Form

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