S.J.M. Vidyapeetha (Regd.,) Chitradurga
SRI JAGADGURU MALLIKARJUNA MURUGHARAJENDRA
INSTITUTE OF TECHNOLOGY
(Affiliated to Visveswaraiah Technological University, Belgaum, Recognised by AICTE, New Delhi)
No.
P.B. # 73, NH – 4 Bye Pass, CHITRADURGA – 577 502. Karnataka State
Tel. : Office : (08194) 222866 Prin. Res. : 230877
Fax : (08194) 227717
Application for admission to First Year B.E., Degree Course for
For the Year
To,
Affix recent passport size
colour photo duly
Attested.
Section :
The Principal
SJM Institute of Technology
CHITRADURGA
Roll No :
University Reg. No :
1. Name of the applicant in full
(in CAPITAL Letters) as in the
marks card of the qualifying
examination
2. a) Nationality
d) Religion
b) Mother Tongue
e) Caste
c) Sex
Male
Female
3. Place of Birth : Village/Town/City
Taluk
District
State
Country
4. Date of Birth
dd
5. Name of the Parent/Gaurdian
relationship (if parent is not alive)
6. Postal adress for all correspondance
(in CAPITAL Letters)
7. Phone Number with STD code
mm
yyyy
2
S.J.M.Institute of Technology, Chitradurga.
8. Occupation of Parent/Guardian
(If parent is not alive)
9.
10.
Annual income of Parent/Guardian
Rs.
Last college/School attended
11. Date of entering the institution
12.
dd
mm
yyyy
dd
mm
yyyy
Date of leaving the institution
13. Name of the Board/University last
14. Details of qualifying examinations passed
Name of the
No.of
Examination
Institution/U attempts
niversity
Year of
passing
Reg.
No
Optional
Subjects
Max.
Marks
Marks
obtained
Percent
age
Max.
Marks
Marks
obtained
Percent
age
Physics
Two Years PreUniversity
Examination
Chemistry
Maths
Total
Examination
Name of the
Institution/U
niversity
No.of
attempts
Year of
passing
Reg.
No
Optional
Subjects
Physics
B.sc. or
equivalent
Chemistry
………………
(specify)
Maths
Total
Examination
Name of the
Institution/U
niversity
No.of
attempts
Year of
passing
Reg.
No
Optional
Subjects
First
Diploma in
Second
………………
Third
………………..
Engineering
Total
Max.
Marks
Marks
obtained
Percent
age
S.J.M.Institute of Technology, Chitradurga
3
15. Institution at which the applicant studied during the last five years. (Reasons for break of continuity
may be stated in the remarks column commencing from Higher Secondary School)
Year
Sl.
Institution
Class
Remarks
No.
From
To
1
2
3
4
5
16. CET Rank
17. CET Admission Ticket NO.
18. Quota of Admission
19. Category of Admission
20. Have you paid fees at CET cell?
(if yes please furnish the following details)
Sl.
Name of the Bank
No.
Yes
Demand Draft No.
No.
Dated
Amount
Total amount paid in words rupees
21. Do you belong to Karnataka State?
If yes how?
If by domicile, have you produced the
Domicile Certificate?
(for Horanada/Gadinada Kannadiga Quota etc.,)
By Birth
22. Branch of Engineering selected (Tick one)
Automobile
Electrical & Electronics
Civil
Electronics & Communication
Computer Science
Industrial Production
Mechanical
Information Science
Yes
By Domicile
No.
Extra curricular activities
(Enclose copies of certificate)
Place:
Date:
Signature of the Applicant
…4
4
S.J.M. Institute of Technology, Chitradurga
DECLARATION BY THE CANDIDATE
I do hereby undertake to complete the B.E., degree course in S.J.M. Institute of Technology, Chitradurga without
seeking transfer to any other Engineering College.
I do hereby certify that particulars furnished above are correct and true the best of my knowledge and if at any
stage found incorrect or false. I understand that my candidature in the college will be forfeited without any prior notice.
I hereby agree, if admitted, to the rules & regulations at present in force or that may here after be made by the
management for the administration of the institute and hostel. I undertake that I will do nothing either inside or outside
the Institute, that will interfere with its orderly management & discipline as long as I am a student of the Institute. I
further agree to make good, when called upon to do so any damage to furniture, apparatus or other articles which may be
caused by carelessness, negligence or wantonness on my part.
I understand I am liable for removal from the Institute for indiscipline or misconduct.
Place:
Date:
Signature of the applicant.
DECALARATION BY THE PARENT/GUARDIAN
I certify that the above particulars furnished by my son/daughter/ward are correct and I undertake to educate my
son/daughter/ward in you institute till the completion of the course.
I undertake the responsibility to pay the tuition and other fees payable to the Institute/Hostel in respect of my
son/daughter/ward and for his/her good conduct throughout his/her stay in the institute.
Place:
Date:
Signature of the Parent/Guardian.
S.J.M. Institute of Technology, Chitradurga
5
FOR OFFICE USE ONLY
The applicant Sri………………………………………………………………………………………………………………
S/o/D/o Sri………..………………………………………………………………………… is selected for admission to
First year B.E., Degree Course during the year……………… …………in ………………………..……….. Branch.
Place:
Administrator
Date:
S.J.M.I.T
Admitted:
Fees paid vide Receipt No………………………………. Date……………………
ATTACH THE RECEIPT HERE
Cashier/Accountant
Registrar, S.J.M.I.T
Principal, S.J.M.I.T
Tick against the options for attested copies of certificates enclosed.
Transfer Certificate
PUC/Intermediate marks card
Degree marks card
Eligibility certificate from Visveswaraiah Technological University
(for student so of other University/Board)
Migration Certificate
Certificate from Head of Institution in which the candidate studies last
Physical Fitness Certificate
Domicile Certificate
Any other Certificates/documents enclosed (specify):
Date :
_______________________ Application received by
6
S.J.M. Institute of Technology, Chitradurga
INSTURUCTION TO THE CANDIDATE SEEKING ADMISSION
1. The Application from should be correctly filled in, and sent to the Principal, S.J.M.I.T., Chitradurga
Karnataka , India with a crossed Demand Draft for Rs.100/- (Rupees one hundred only) drawn in favour of the
PRINCIPAL, S.J.M.I.T., CHITRADURGA, payable at Chitradurga , towards Registration fee of application and
with the documents securely fastened to application, so as to reach him on or before the due date. The
Registration fee is not refundable.
2. MINIMUM QUALIFICATION : Two year Pre-University Examination of the Karnataka Pre-University
Education Board any equivalent examination with a minimum of 35 percent marks on the aggregate in the
Science Group i.e., Physics, Chemistry and Mathematics in the final examination and English should be as a
subject of study.
3. Students from other Universities, Board, Should produce the ELIGIBILITY CERTIFICATE FROM THE
REGISTRAR, VISVESWARAYA TECHNOLOGICAL UNIVERSITY, BELGAUM.
4. Students coming from the other Universities should also produce Migration certificate at the time of admission.
5. Application with incomplete information is liable to be rejected.
6. Application received after the due date will not entertained. Only attested copies of the required certificates are to
be enclosed to the application and the Original Certificates should be produced at the time of admission.
7. Candidate called for interview, should appear before the selection committee, at their own cost.
8. Candidates called for admission would be intimated by ordinary post.
9. The management reserves the right to cancel the admission of a candidate at any stage, if and when it is detected
that the admission is against the rules.
INSTRUCTION FOR FILLING UP THE APPLICATION FORM
1. All entries should be made by ball point pen only and should be neatly written without any corrections.
2. While entering the names & addresses in the boxes, they should be written in Capital letters only as in the
following example: Enter the name Mahesh V Bhupathi as
M
A
H
E
S
H
V
B
H
U
P
A
T
H
I
3. Date of birth and other dates should be entered clearly Date first, Month next and full year as per the following
example : Enter the date 31st March 1982 (or 31.3.82 ) as
3
1
dd
0
3
mm
1
9
8
2
yyy
4. For entering phone number with STD code, write STD code first followed by a hyphen
(-) , for example to enter STD code : 08194 & Phone no.: 427717.
0 8 1 9 4 - 4 2 7 7 1 7
5. For items 16 to 21 enter the details as given through CET and for item 22 tick any one of the branch of
engineering as allotted by the CET Cell at the time of counselling. Any descripancies found from the verification
from the CET Cell, the candidate is liable to be rejected summarily.
6. For further details contact Exam Section – in charge, SJM Institute of Technology, Chitradurga.