MOHAMED SATHAK A.J. COLLEGE OF ENGINEERING An ISO 9001:2008 Certified Institution # 34, Rajiv Gandhi Road (OMR), IT Highway, Siruseri, Egattur, Chennai - 603 103. Tamilnadu, India. Ph:- 044-27470021 to 27, 82, 83, Admission:- 044-27470025 E-mail:- admission@msajce-edu.in, www.msajce-edu.in Approved by A.I.C.T.E., New Delhi & Affiliated to Anna University Chennai APPLICATION FORM FOR ADMISSION TO THE B.E. / B.Tech. / M.E. COURSES Application No.: Academic Year: 2017-2018 Category: Government Quota / Management Quota Write your choice of courses for admission (1,2,3,...) S.No. U.G. Courses Offered S.No. P.G. Courses Offered 1 B.E. Aeronautical 1 M.E. Computer Science and 2 B.E. Civil 2 M.E. Power System 3 B.E. Computer Science and 3 M.E. Structural 4 B.E. Electronics & Communication 5 B.E. Electrical & Electronics 4 M.E. Thermal 5 M.E. VLSI Design 6 B.E. Material Science & 7 B.E. Mechanical 8 B.Tech. Information Technology 1. Name (in block letters ) 2. Gender ( ) Male Female 3. Name of Parent / Guardian Space for affixing Passport size photo 4. Date of Birth & Age Date Month Year Age Date, Month, Year should be entered only as a two digit number 5. Blood Group 6. Place of Birth 7. (a) Address for Communication 7. (b) Permanent Address Pincode Pincode Mohamed Sathak A.J. College of Application Form 1
8. Community ( ) BC BCM MBC DNC SC SCA ST Others 9. Nationality 10. State 11. Religion 12. Caste 13. Mother Tongue 14. Contact Phone No (Parent) 15. E-Mail ID 16. Educational Details S.No. Class (1) X Std (2) HSC / Equivalent (3) Diploma (4) Degree Register Year of Medium of Name and Address of the Number Passing Instruction Institution 17. Student Bank Account Details Bank Name IFSC code Bank Account Number Branch Name MICR Number 18. Aadhaar Card No 19. Do you need college transportation facility / Hostel facility If transport, specify pickup point 20. Extracurricular activities ( ) Sport Games N.C.C. Special Service Others Mohamed Sathak A.J. College of Application Form 2
Admission seeking for B.E. / B.Tech. / B.E / B.Tech. (Lateral) 21. Marks details in the Qualifying Examination (a) HSC / EQUIVALENT (Academic) Marks Scored Cut off Subjects out of 200 Marks Physics (P) Chemistry (C) Mathematics (M) Total (b) HSC (Vocational) Marks Scored Subjects out of 200 Mathematics Theory Practical I Practical II Total Cut off Marks (c) DIPLOMA Branch: Sem I Sem II Sem III Sem IV Sem V Sem VI Sem VII Sem VIII Percentage: Class : (d) B.Sc. Major: Whether the student studied mathematics as a subject in HSC and B.Sc. Yes / No Sem I Sem II Sem III Sem IV Sem V Sem VI Sem VII Sem VIII Percentage: Class : Mohamed Sathak A.J. College of Application Form 3
22. Admission seeking for M.E. Qualifying Examination: B.E. / B.Tech Register Number Year of Passing Branch Class CGPA Whether the student appeared Tamil Nadu Common Entrance Test (TANCET) Yes / No If yes Register Number Score 23. Marks Obtained in UG Degree Course Sem I Sem II Sem III Sem IV Sem V Sem VI Sem VII Sem VIII CGPA Class 24. Details of Father, Mother & Guardian Father Mother Guardian Name Qualification Occupations Office Address & Phone Number Phone No. Email Id Annual Income Signature JOINT DECLARATION BY THE CANDIDATE AND PARENT / GUARDIAN The information furnished above is true and correct to the best of our knowledge. The original certificates will be produced at the time of admission. In case any information furnished above is found to be incorrect / false at a later date on verification, we agree to forego the admission and also to forfeit the fees, if any, paid till such time. Signature of the Parent / Guardian Signature of the Candidate Place: Mohamed Sathak A.J. College of Application Form 4
OFFICE USE ONLY CHECK LIST TICK 1. T.C. from the institution last studied 2. Mark Sheet in the qualifying examination S.S.L.C H.S.C Diploma B.Sc B.E. / B.Tech 3. Attested copy of Permanent Community Certificate Card 4. Attested copy of TANCET Mark sheet (for PG admission) 5. Diploma / Degree / Provisional Application Completed Yes No The Candidate is eligible Yes No if not eligible, Specify the reason Name and Signature of the Scrutinizing Staff: Mohamed Sathak A.J. College of Application Form 5
AFFIDAVIT BY THE CANDIDATE I... S/o / D/o...seeking admission in the I Year / II Year B.E. / B.Tech. / M.E. Degree course during the year 2017-2018 is fully aware of the law regarding prohibition of ragging as well as the punishments and if I found guilty of offence of ragging and / or abetting ragging is liable to be punished appropriately. Place: Signature of the Candidate AFFIDAVIT BY THE PARENT / GUARDIAN I... F/o / G/o...is fully aware of the law in this regard (ragging) and agree to abide by the punishment meted out to my ward in case if my ward is found guilty of ragging and /or abetting ragging. Place: Signature of the Parent / Guardian Mohamed Sathak A.J. College of Application Form 6