Lakhmi Chand Institute of Technology Bilaspur
Approved by AICTE & affiliated to CSVTU Bhilai
FOR ADMISSION : 9630052722, 9179080002/3
     

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Admission Form


Course Applied (BE) :
Computer Science Electronics & Communication Engineering
Mechanical Engineering Civil Engineering
Electrical Engineering Electrical & Electronic Engineering

Personal Details

Name (In Capital Letters)
Father’s/Husband’s Name
Mother’s Name
Permanent Address
Phone No.  
Local Guardian’s Name
Local Guardian’s Address
Phone No.  
Date of birth (DD/MM/YYYY)
Age (As on 1 July)
Sex
Male Female
Blood Group
Category/Caste
SC ST OBC GEN
Marital Status
Married Unmarried
Nationality
Indian Other
Profession of Parents/Guardian
Approximate Annual Income of the family (in Rs.)
Less than 1,50,000 1,50,000 to2,00,000
2,00,000 to 2,50,000 More than 2,50,000
Details of Qualifying Examination
1.
Percentage of marks in Graduation     Marks obtained  
Total Marks  
2. Medium of instruction at (10+2) level  
3.
Percentage of marks in 10+2(PCM)     Marks obtained  
Total Marks  
4.
Score & Rank of     Exam  
Score     Rank  
Extra Curricular Activities/Achievements (Specify)
Academic/Literary : Sports :
Cultural: Social :
Campus/NCC/NSS: Others:
Are you presently doing any other academic courses?
Yes No
If yes, give details:
Have you ever been suspended or placed on academic probation at any previous institute ?
If yes, give details:
Do you require Hostel facility ?
Yes No
Check list for enclosures
Birth Certificate Transfer Certificate
Migration Certificate (if applicable) Character Certificate
Gap Certificate (if applicable) Marksheet of 12 /Graduation
Domiscile Certificate Photographs of parents
Photograph of local guardian Photographs of applicant (8 copies)
Any other certificate (if applicable)
Total number of enclosures

Declaration by Student

I promise to abide by all the rules, regulations and code of conduct as framed by the Institute/ University. I will accept the decision of the Institute/University, regarding the admission, as mentioned in the Prospectus/Admission form.
Date:  
Place : Name and Signature of Applicant

Undertaking of the Parent/Guardian

I hereby undertake that my ward shall follow the rules and regulations framed by the Institute/ University, as mentioned in the prospectus and as amended from time to time. .
Date:  
Place : Signature of the Parent/Guardian
I have read all RULES & REGULATIONS.