Final Allotment For office use Category No. office use only Application no. office use only Merit No. K. J. Somaiya College of Engineering, Vidyavihar, Mumbai-77 (Autonomous College Affiliated to University of Mumbai) Application 2014-15 (Minority Seats) Pre Admission Form for PG Course in (Submit Separate Application per Branch of Interest) (Submit Separate Application for Each Category) GATE Score Record Discipline Score Year of Passing Affix Recent pass port size Colour Photograph Category No. I II III Category Gujarati Linguistic Minority with NON ZERO GATE score Linguistic minority such as Urdu, Hindi, Kannada, Bengali, Telugu, Tamil, Oriya, etc. with NON ZERO GATE score Religious minority such as Muslim, Christian, Jain, Parsi, Sikh and Bauddha with NON ZERO GATE score Please Tick Personal Details Last Name / Surname First Name Signature of the candidate Middle Name Mother s Name Nee Name (Name after marriage, if applicable) Present Address Tel. No. : E-mail: (M): Pin Code: 1 Date and Place of Birth: (dd/mm/yy)
Permanent Address Sex: M / F Mother Tongue: Category: Reserve/Open Caste (If Reserve Category): Blood Group: Nationality: Pin Code: Marital Status: Married / Un-married For GATE students (not mandatory) ADHAR Card No: Nationalized or Schedule Bank Account No. (Core banking): Qualification Year of passing qualifying degree Title of qualifying Degree Name of the Institute Name of the University *Year of admission to first year: Year of admission to second year: Year of admission to third year: Year of admission to fourth year: (Attach attested copies of mark list and certificates) Marks Maximum Obtained Marks Pre final V Semester Percentage of Marks year VI Semester Final year VII semester VIII semester *Diploma to degree students may write year of admission as second year 2
DECLARATIONS/UNDERTAKINGS/CERTIFICATES DECLARATION BY GATE CANDIDATES I have been admitted to the M. E. programme in ---------------------------------------------------- in GATE category and I am eligible to get AICTE PG scholarship. However, I understand that disbursement of the scholarship depends on the grants received from the AICTE and for which I will not hold the institute responsible. I will follow the rules and regulation laid by AICTE for the GATE PG candidates from time to time. Date: Name and Signature of the Candidate DECLARATION BY CANDIDATES WHOES RESULT OF QUALIFYING BACHELORS DEGREE IS AWAITED I understand that I have been admitted to the M. E. programme in ------------------------------- on provisional basis and my admission will be confirmed only after producing my passing certificate and the mark sheet of qualifying degree examination from the concerned University on or before September 2014. Date: Name and Signature of the Candidate DECLARATION BY CANDIDATES FROM ALL CATEGORIES I hereby declare that the above information is correct to the best of my knowledge and belief. I further understand that if any information in this form is found incorrect, my admission is liable to be cancelled. Date: Name and Signature of the Candidate 3
SPONSORSHIP LETTER (To be filled in by sponsoring organization on their letter head only) Mr./Ms. is a full time employee of our organization since...we hereby sponsor him/her to join the Post-Graduate Program in -------------------------------------------------------------------------------at K. J. Somaiya College of engineering, Mumbai-77. We shall relieve him/her of all responsibilities in our organization throughout the period of study to enable him/her to pursue the study on full time basis. Signature of Sponsoring Authority with seal AFFIDAVIT FOR MINORITY Form of affidavit to be made by the candidate on non-judicial stamp paper of 100/- (Rupees One Hundred Only) before a Notary or Executive Magistrate or a Metropolitan Magistrate I,. an Indian inhabitant, residing at. son / daughter of Shri.. wife of Shri.. an Indian inhabitant, do hereby solemnly affirm and say that I belong to the speaking Community, which is a linguistic minority in the State of Maharashtra. Solemnly affirmed at.. this.... day of., 2014. Identified by.... (Signature of Candidate) Before Me 4
COMMUNITY CERTIFICATE Pro forma for certificate from a registered community organization on its letterhead for Candidates seeking admission in Minority Quota (should be in English or in devnagari script only) This is to certify that Shri./Ms.... son / daughter of Shri. wife of Shri.. Residing at. belongs to. which is a speaking linguistic minority community in the State of Maharashtra. Hon. Secretary / Chairman for Seal (Name of the Organization) Address & Tel. No. of the Organization: Date:. Registration No.: 5
AFFIDAVIT FOR RELIGION Form of affidavit to be made by the candidate on non-judicial stamp paper of 100/- (Rupees One Hundred Only) before a Notary or Executive Magistrate or a Metropolitan Magistrate I,. an Indian inhabitant, residing at. son / daughter of Shri.. wife of Shri.. an Indian inhabitant, do hereby solemnly affirm and say that I belong to the Religion, which is a minority religion in the State of Maharashtra. Solemnly affirmed at.. this.... day of., 2014... (Signature of Candidate) Identified by.. Before Me RELIGION CERTIFICATE Pro forma for certificate from a registered community organization on its letterhead for Candidates seeking admission in Minority Quota (should be in English or in devnagari script only) This is to certify that Shri./Ms.... son / daughter of Shri. wife of Shri.. Residing at. belongs to. which is a religion in the State of Maharashtra. Hon. Secretary / Chairman for Seal (Name of the Organization) Address & Tel. No. of the Organization: Date:. Registration No.: 6
For office use only Check list for attested copy of certificates attached Sr. No Description of certificate Tick mark 1. GATE Score Card 2. First Year mark list (Sem. I & II)/Diploma final year mark list and certificate 3. Second Year mark list (Sem. III & IV) 4. Third Year mark list (Sem. V & VI) 5. Final Year mark list (Sem. VII & VIII) 6. Qualifying degree certificate / passing certificate 7. College leaving certificate 8. Domicile certificate (mandatory for minority seats) 9. Community / religion certificate (mandatory for minority seats) 10. Affidavit (mandatory for minority seats) 11. Proof for Indian nationality 12. Proof of change in name / surname (if applicable) 13. ADHAR Card (not mandatory) Details of the DD/Pay order/account payee cheque# Date DD Number Name of Issuing Bank Amount 1000/- # Demand draft / Pay order / Account Payee cheque for 1000/- should be in favor of The Principal K. J. Somaiya College of Engineering payable at Mumbai of Nationalized / Schedule bank. Application fee is per application per branch per category. If application is submitted in person then payment through credit card also accepted. Signature of accountant Checked by Verified by 7