A19TW140655

Birla Institute of Technology & Science,Pilani,Rajasthan

Work Integrated Learning Programmes Division

Application for Admission to B.Tech. in Information Systems (SIM) for 2022

For Office use only

ID No: 202219TW______ Date of Receipt:_________________

Remarks,if any:________________________________________

Dean Vice-Chancellor

Note:Please read the instructions carefully before filling in this application form.

SECTION 1:PERSONAL INFORMATION & EDUCATIONAL BACKGROUND

1.Name: Aditi Pandey

2.Gender: Female
3.Date of Birth: Feb. 5, 2004
4.Father's Name: Alok Pandey
5.Mother's Name: Uma Pandey
6.Email: [email protected]
7.Mobile/Phone: +91 83036 16725/+91 82990 47493
8.Nationality: Indian
9.Do you belong to Scheduled Caste or Scheduled Tribe?[Y/N] ___
10.Address for Correspondence: C/O: Alok Pandey, Bathua
Sadar, Near Polytechnic College
Gate1
Mirzapur(231001), Uttar Pradesh
Mirzapur,Uttar Pradesh,India
11.WIPRO Employee ID : NA

12.Educational details from School Leaving Certificate onwards in chronological order:

Name
Total
Qualification of Subject/ Year of Maximum Final
Duration(Years) Marks Division
Level Diploma/ Branch completion Marks Marks
/CGPA
Degree

10th level,
10th Grade 10th
matriculation 1 year 2019 91.20 1st division
(Matriculation) MATRICULATION
or equivalent

INFORMATION
10+2 level, Diploma (3 SYS. &
3 year 2022 85.52 1st division
Diploma 3 yr year) INFORMATION
TECH.

1
 A19TW140655
*As Calculated for declaring result and award of Division by your Board / university.If marks are not awarded,give Cumulative Grade Point Average Or
its equivalent.Explain below the basis on which your B. SC. / B.E. M. SC. / M. C.A. (Or equivalent)final percentage is Calculated (Cleary explain gaps, if
any in a separate Sheet.)

13.Level at which you have studied Mathematics: Till Intermediate(Std. XII)

14.Are you currently enrolled for degree or diploma in any University/Institution: (Y/N) N

If Yes,give details specifying the University Institution name,programme name,duration,date of joining the programme and likely date of completion of the same.

15.Have you ever been a student of BITS,Pilani.(Yes/No):if yes,please write name of the degree and your ID No.:

16.Exam Centre Choice: Noida (Uttar Pradesh)

Note:In case exam centre is not indicated the institute will unilaterally assign a Centre.The Institute is also free to demand that students come to an Exam Centre other than the one indicated above.Further,in case of
Dubai centre there will be an additional exam centre fees,which will be indicated at the time of admission.

17.Current Employment Status: Employed

18.Total Work Experience: 0 Years 8 Months 14 days

19.Work Experience in Current Organisation: 0 Years 8 Months 15 days

(as on applicable deadline to be counted only from the point of completing BE/MSc or equivalent))

20.Employment Details:Since the year of completing BE/MSc or equivalent,give brief employment details below in reverse chronological order.

Name of Employer Designation held Start Date End Date

Total Work Experience calculated after completing BE/MSc or

equivalent

Provide the dates of start end of the employment period.Clearly explain gaps,if any in a separate sheet.

21.Declaration by the Applicant

I have carefully read the details and the instructions given in this form and hereby declare that all the information given and statements made in various sections
and parts of this Application Form and enclosures are true to the best of my knowledge. I agree to the condition that if information or statement were found to be
wrong, my admission to BITS would automatically be cancelled. I understand that the objective of the Institute will be to examine in detail my educational and
professional background along with my employer's visualization of my current and future professional involvement to accommodate my Career aspirations within
the framework of an appropriate learning avenue. I thus realize that in this process of matching, the Institute instead of rejecting my application for admission may
even Suggest that I would be more suitable for another degree programme / area of study for which I have not applied. If admitted,I promise to abide by the Rules
and Regulations in force or those that may hereafter be made by the Institute and I shall do nothing either inside or outside the Institute which will interfere with its
orderly working and discipline.I promise to be regular in the study schedule and in appearing in the examinations at allotted centre. If I am required to Pilani for
any examination,I shall take permission from my employer for appearing in the same. In the case that I myself will be paying my fees / dues,I affirm that I will
regularly pay fees/dues to the Institute during my programme. Further, in all matters concerning the Institute and myself the decision of BITS Vice-Chancellor
shall be binding on me.

Place:________________________ Signature:_____________________
Date:________________________ Name:

2
 A19TW140655
MANDATORY SUPPORTING DOCUMENTS

To complete the application submission process, candidates are required to submit copies of supporting documents through the Application
Centre.

Before uploading scanned copies of the mandatory supporting documents listed below, please ensure that they are complete in all respects, failing
which your application will be considered as incomplete and rejected. Each uploaded document should be SELF ATTESTED by you using
your FULL SIGNATURE. Please attest all pages of documents you upload.

For certain documents such as marksheets where multiple pages may need to be uploaded, you may scan multiple pages into a single
pdf file and upload it. Alternatively, you may scan different pages as separate pdf files, then create a zip file of these pdf files and upload
it as a single zip file.

Documents to be uploaded

1. Application Form: This implies pages 1 & 2 of the downloaded pdf of the Application Form. Upload a single pdf file containing the two pages scanned together,
or a zip file that has separate pdf files for each page. Ensure that all additional information required therein has been filled legibly by hand, and photograph
and signature are present.
2. Photograph: Upload a soft copy of a professionally taken passport-sized photograph.
3. Degree Certificate(s): Upload scans of your 10th, 10+2 and degree / diploma certificates that include your name. Upload all documents as a multi-page pdf or
a zip file.
4. Proof of Date of Birth: Upload a photocopy of your 10th Pass/ Matriculation/ Secondary School Leaving Certificate/ Marksheet clearly stating your date of birth.
5. Marksheet(s): Upload academic marksheets for all years/ semesters of all your 10th, 10+2 and degree/ diploma examinations. Upload all marksheets together
as a multi-page pdf, or a zip file.