VISHWAKARMA MARITIME INSTITUTE

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BRACTs

VISHWAKARMA MARITIME INSTITUTE

Sr. No. 2, Kondhwa Budruk, Pune – 411 048

*Approved by Directorate General of Shipping, Ministry of Shipping, Govt. of India & affiliated to Yashwantrao Chavan Maharashtra Open University(YCMOU), Nashik,a State Own University

VMI/FF-24 B 1 6/04/2012 Rev. No.0 Iss. No 1

Website: www.vmipune.com

E-mail: [email protected]

ADMISSION FORM

B.TECH. MARINE ENGINEERING (4 YEARS) PERSONAL DETAILS: 1.

Name of the candidate in BLOCK LETTERS.

APPLICATION NO.

2.

4.

Sex: (As per Higher Secondary School or Equivalent Certificate) Nationality: Male Female

3.

5.

Religion: Marital Status: Single Married .

passport size photograph here (Taken within six months) 6.

(a) Date of Birth (in figures) : Date (b) Age: Yrs Month Year Months (The applicants should be lesser in age than 25 years on 1 st of August 20 14 ) (c) Place of Birth: Village/Town/City. Dist State:

7.

1.Name of Father / Guardian: 3. Permanent Address: 4. Present Address: 2. Occupation: _ Pin Code: State: 5. Contact for communication: a) Residence (R): c) Mobile No: Pin Code: b) Office (O): c) E-mail ID: State:

8. Detail of Demand Draft:-

Amount :Rs.1

5 00/- D.D. No.

issuing bank & branch

9.

Career Adviser (If any) : Source of your information about VMI: 1 Da te:-

ACADEMIC RECORD: 10 . 10 th (X) /SSC/Equivalent Exam.

Year of passing Board State Marks Obtained in English Subject Maximum marks Marks obtained (%) 1 1 . 12 th (XII) /Higher Secondary or Equivalent Exam.(Science stream)

(a) Name of School / College with complete postal address, from where the applicant has passed / appeared in the 12 th /Higher Secondary / Equivalent Examination Pin Code State: (b) State whether the applicant has passed the qualifying examination (12 th ) or appearing this year and the result is awaited? (Strike out whichever is not applicable) Passed Appeared but result awaited Appearing for improvement (c) Details of Qualifying Examinations:

Name of Examination Board / University State Exam. Seat No./ Roll No Year of passing

12 th (XII) /Higher Secondary or Equivalent (Science stream) (d) Marks of 12 th.

/ Qualifying Examination, if passed. (Aggregate …………….. %)

Subjects Maximum Marks Marks Secured Physics Chemistry Mathematics Cumulative Physics, Chemistry & Mathematics Percentage: Percentage % % % % English

----------------------------------------------------------------------------------------------------------------------------------------------- -

% 1 2 .

Extra Curricular Activities (Tick Sports Games in appropriate choice) N.C.C

Social service Any others

1 3 .

How do you intend to meet the expenses of this course? (Tick Own Resources Relative Resources in appropriate choice) Bank Loan Others

1 4 . Declaration by the applicant:

I solemnly declare that all the particulars stated in this application are true to the best of my knowledge and belief. In the event of my being found ineligible even at a later date, I understand that my admission will be cancelled.

Signature of Applicant (Mr/Mrs……………………………… .....................) Place: Name & Signature of Father / Guardian Date: 2

EXAMINATION CENTRE COPY

BRACTs

VISHWAKARMA MARITIME INSTITUTE

Sr. No. 2, Kondhwa Budruk, Pune – 411 048 To be filled in by office

APPLICATION NUMBER:

To be filled in by the candidate Name in BLOCK LETTERS: Father’s Name: Address:

Affix recent passport size photograph here (Taken within six months)

PIN Code:_ District:_ State: ( Signature of the Applicant)

Admission In charge

CANDIDATE COPY

BRACTs

VISHWAKARMA MARITIME INSTITUTE

Sr. No. 2, Kondhwa Budruk, Pune – 411 048 To be filled in by office

APPLICATION NUMBER:

To be filled in by the candidate Name in BLOCK LETTERS: Father’s Name: Address:

Affix recent passport size photograph here (Taken within six months)

PIN Code:_ District:_ State: ( Signature of the Applicant)

Admission In charge

3

Sr.No

4 5 1 2 3 6 7 8.

VERIFICATION OF ORIGINAL DOCUMENTS Documents Status

At the time of Admission Round 10 th 10 th 12 th Mark sheet Passing out /Board Certificate Mark sheet Transfer Certificate Age Certificate Migration Certificate

PCM:

Maximum Marks Age as on 1 st August 201 4 :

Remark:

Date of Birth: Date

OFFICE COPY

Marks Obtained: Years _ Months Month Year At the time of Joining the Institute Percentage %

Name & Signature of the Verifying Officer ADMISSION AUTHORITY

The Candidate has been found physically Fit

/

Unfit by a doctor approved by the Directorate General of Shipping during his admission process and admitted to the 1 st year of B.Tech. Marine Engineering / B.Sc. Nautical Science Degree course of our institute in the year 1 st August, 20 __

Admission In charge Director

CHECK LIST FOR CANDIDATES:

Before submitting your Application Form please ensures following points: 1

Name written at all places in the form should be identical

2

Please Tick [

]

Your photograph on page no.1 has been signed by you & other two should be pasted on page no.3

3 4

Admission form signed by your father / guardian.

Application form must be submitted in an envelope super-scribed with the words in accordance with Course applied for.

"Application for admission to B.Tech Marine Engineering" Or "Application for admission to B.Sc. Nautical Science"

5 6

7

Demand Draft of Rs.1

5 00/- in favour of “Vishwakarma Maritime Institute” payable at Pune.( Write your name and contact number on back side of D.D. ) Your age as on 1 st Aug.201

4 is below 25 years.

Your signature at all appropriate places

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