Applicant's Name(as per HSCE record)
Father's/Guardian's Name
Father's/Guardian's Occupation
Phone Number
Mobile Number
Email
Correspondence Address
Address
PIN Number
Permanent Address
Sex Male Female
Date of Birth
Place of Birth
Date of Birth(State)
Hobbies
Blood Group
Religion
Category SC ST OBC GEN OTHERS
Mother Tongue
School of Engineering Campus applied for : 1. Paralakhemundi 2. Bhubaneswar (Please tick appropriate option. You can tick both if you do not have any preference for a particular campus. Campus will be allotted as per choice and merit list. Branch choice will be as per merit list)
Academic Qualification
Percentage scored in MPC/Group taken togather at the qualifying Examination in (%)
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DD No:
DD drawn Date:
Name of the Bank:
I hereby solemnly declare that all the particulars given in this form are true to the best of my knowledge and belief. I shall abide by the rules and regulations laid down by the college from time to time. In case the particulars furnished by me are found false, my admission stands cancelled.
