GOJAN

SCHOOL OF BUSINESS AND TECHNOLOGY

Approved by A.I.C.T.E, New Delhi. & Affiliated to Anna University, Chennai.
NAAC Accredited Institution | An ISO 9001 : 2015 Certified Institution Space for affixing recent
Edapalayam, Redhills, Chennai - 600 052. passport size photograph
Phone: 044 - 2631 1001/1045/1025, Mobile: 91763 78086, 7010723984 duly attested

E mail: [email protected], [email protected] by Gazetted Officer

Website: www.gojaneducation.com

Application No. GSBT

Application Form for Admission to

M.E / M.B.A / B.E. / B.Tech Degree Course for the Year 20 - 20

1. Name of the Student :

(As on S.S.L.C. std / intermediate Mark sheet in Block Letters)

2. Name of the Parent / Guardian :

3. ADDRESS FOR COMMUNICATION

Door No / Street :

Town : Pin Code :

District : State :

Phone Res : Off : Mobile :

E-mail ID :

4. Gender : Male Female

5. Date of Birth : Date Month Year

(Attach True Copy of T.C.
from Institution Last stud-
ied)
Municipality Corporation

6. Place of Birth (Village / Town / City) :

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7
8. Native District & State :
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9. Are you a citizen of India : Yes No

10. If ‘No’, Mention Country’s Name :

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11. Religion :
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12. Community : BC MBC SC ST Others
Paticulars only for ST, SC, MBC, BC Only
(i) Name of the Caste :

(ii) S.No. & Date of the Community Certificate :

(iii) Designation & Office of the issue Community Certificate :

13. Mother Tongue :

14. Occupation of the Parent / Guardian :

15. Monthly Income of Parent / Guardian :

16. Indicate the Branch in the order of preference :

(i) Aeronautical Engineering 1)

(ii) Computer Science and Engineering 2)

(iii) Civil Engineering 3)

(iv) Electronics and Communication Engineering 4)

(v) Electrical and Electronics Engineering 5)

(vi) Mechanical Engineering 6)

(vii) Information Technology 7)

(viii) M.E - Applied Electronics 8)

(ix) M.E - Computer Science & Engg. 9)

(x) M.E - Power Electronics & Drives 10)

(xi) M.E - CAD/CAM 11)

(xii) MBA - Master of Business Administration 12)

17. (a) Extra Curricular Activities Sports YRC NCC NSS Others

(Original Certificate must be produced

at the time of admission)

18. Qualifying Examination Passed HSC (Academic) HSU (Vocational) HSC (CBSE)

Degree Diploma Intermediate (A.P.) Others

19. Medium of Instruction Tamil English Others

20. Details of the Qualifying Examination :

Reg. No. Year of Passing

21. Name of Hsc.School / Jr.College / College :

Address

22. No. of appearance in the qualifying exam One Two

23. General Rank Consortium AU AIEEE

24. Marks in the qualifying Examination (Attach a true copy of mark sheet)
(a) HSC (Academic / Equivalent

Subjects Month and Maximum Marks Total

Register No.
Year Marks Obtained Percentage
Physics (P) ................................ ..................... .................... .................. .................

Chemistry (C) ................................ ..................... .................... .................. .................

Mathematics (M) ................................ ..................... .................... .................. .................

Total

(a) HSC (Vocational)

Month and Maximum Marks Total

Subjects Register No.
Year Marks Obtained Percentage

Related Subjects
Related Subjects - I ................................ ..................... .................... .................. .................

Related Subjects - II ................................ ..................... .................... .................. .................

Vocational Subject
Theory ................................ ..................... .................... .................. .................

Practical - I ................................ ..................... .................... .................. .................

Practical - II ................................ ..................... .................... .................. .................

Total

(C) Diploma Examinations

Subjects Month and Maximum Marks Total
Register No.
Year Marks Obtained Percentage
Pre - final Semester ................................ ..................... .................... .................. .................

Final Semester ................................ ..................... .................... .................. .................

Total ................................ ..................... .................... .................. .................

(d) School of Study (Attach a true copy of Xth Mark Sheet)

S.No. Class Year of Name of the School / Village / Total

State
Passing Polytechnic / Institution Town / City Percentage
1. X Std ............... ................................................. ...................... ..................... ...................
2. HSC/Equivalent ............... ................................................. ...................... ..................... ...................
3. Diploma ............... ................................................. ...................... ..................... ...................
4. Degree ............... ................................................. ...................... ..................... ...................

25. Category under which admission is sought ;

(a) Govt (b) Management

26. If Govt candidate mention the category under which a admitted?

(a) Sports (b) Ex-servicemen (c) Freedom Fighter

(d) Physically handicapped (e) Community (f) Open Category

27. Other Facilities :

a) Hosteller Veg Non veg

b) Day Scholars Veg For First UG & PG Mess Compulsary.

Break Fast : Yes No

Lunch : Yes No

c) College Transport Yes No

Boarding Point :

28. For Office Use

Admission Details :

1. Admission No. :

2. Course Allotted :

3. Eligibility : Eligible / Not Eligible

4. Stay : Hosteller / Day Scholar

Admitted / Not Admitted

Verfied by :
Signature : Signature of Principal

ENCLOSURES WITH THE APPLICATION

The Application should be sent along with the following 2 sets of Xerox Copies of Certificates.
However the Original Certificates must be produced of the time of admission
1. 10th or SSC and or Equivalent Certificate / H.S Vocational Certificate / Diploma / Degree / Certificate
2. Transfer Certificate.
3. Conduct Certificate.
4. Community Certificate.
5. Extra Curricular Activities Certificate if any.
6. General Rank Card issued by Consortium or A.U.
7. Anna University Allotment order, (Single window candidates only)
8. Medical Fitness Certificate with Blood group
9. Migration Certificates (Compulsary for students from states other than Tamilnadu).
time of admission.
10. Eligibility Certificates (Applicable only for other state students) must be produced at the
time of admission.
11. Proof for date of birth.
12. Six passport size photo (Names Written on the back)
 JOINT DECLARATION BY THE APPLICANT AND PARENT

I hereby solemnly and sincerely affirm that the statements made and the information furnished by
me in the application as also in the enclosures there to, submitted by me are true. Should it, however be
found that any information furnished therein is untrue in material particulars or on verification at a later stage,
I am liable for criminal prosecution and, I also agree to the forfeiture of my Son’s / daughter’s / ward’s seat,
in this Institution at whatever stage of study my son/daughter /ward may be at that time of detection of such
wrong particulars. I also affirm :

1. That my son/daughter/ward would strictly adhere to all the rules and regulations in force now or
which may be introduced in the institution hereafter and that breach of discipline and rules by my
son/daughter/ward entail summary forfeiture of his/her seat in the institution.

2. That I am aware that it my son / daughter / ward does not put in a minimum of 80% attendance during
the year, in theory, drawing and practical classes separately, my son / daughter / ward will not be
sent for the University Examination.

3. That I am aware that the curriculum for the various courses is not rigid and my son / daughter / ward
will follow the syllabi for the various courses in force at the time of his / her admission and that any
revision or modification made in the syllabi during the course of his / her study in the Institution will be
binding on him / her.

4. That I am aware that if my son / daughter’s / ward’s does not get a minimum of 60% of marks in the
day today valuation of his / her work and progress, he / she may not be sent for the University
Examination.

5. That in the case of my son’s / daughter / ward progress in studies in uniformly poor in the institution
his / her studies are liable to be terminated by the issue of Transfer Certificate.

6. That in case my son / daughter / ward, becomes a scholarship holder or comes to enjoy educational
concessions like half fees or full fees etc., and does not show special progress, the scholarships or
educational concessions are liable to be cancelled and that if my son’s / daughter’s / ward’s conduct
and character are not good these will be cancelled summarily.

7. That my son / daughter / ward is aware that breach of discipline and rules or bad conduct in the
institution or extra curricular activities will also entail summary forfeiture of seat in the institution, in
addition to such other proceedings proceedings that may be taken against him / her.

8. That I am aware that if my son / daughter / ward is admitted into the hostel he / she will strictly abide
by the rules and regulations is force in the hostel and that any breach of discipline or rules or any
unruly conduct or undersirable activities will be summarliy dealt with be forfeiture of seat both in the
hostel and the institution in addition to such other proceedings that may be taken against him / her.

9. That in case the qualifications possessed by my son / daughter / ward are not recognized by the
Anna University for admission to the M.E / M.B.A / B.E. / B.Tech. Degree Course in the Engineering
College my son / daughter / ward will discontinue the course forthwith, and college will not be
responsible for admitting him / her.
10. That no request for changes to any course other than the course to which my son / daughter / ward
admitted will be will be entertained.

11. That the admission to the college does not guarantee admission to the hostel.

12. That my son / daughter / ward should not involve himself / herself in strikes, unlawful assemblies,
consumption of intoxicating drinks and drugs, the late attendance or any other infringement of rules
and regulation and refusing to accept the criminal punishment ordered by the Principal / Management.

13. I agree to abide without any objection or appeal to anyone and to hold it as binding on me any action
or decision taken by the Principal of the discretion or to terminate my son’s / daughter / ward’s
studies and to leave the college.

14. I agree to pay the fees fixed by the Government and Self Financing College and Maintenance charges
fixed by the Management at the time of admission.

15. I agree that I will not participate in the ragging of students. I am aware that it is a serious offence
delared by the Government punishable Under criminal law.

16. I will strictly comply with the dress code of the college.

17. I will not use cell phones / Electronic gadgets in the Campus.

I also agree that if there is any revision in the fee structure at a later date, the amount payable will be
on that basis.

Signature of the Parent / Guardian

I am fully aware of the declaration and I have understood the same. I agree to the above conditions.

Place : .......................................

Date : ....................................... Signature of the Applicant

Note : The Guardian may execute the above condition, only if both the parent are not alive.