Sl No ..........................

PILOO MODY COLLEGE OF ARCHITECTURE

Under
ABIT GROUP OF INSTITUTIONS
PLOT NO11/ 1/ A, CDA SECTOR1, MARKAT NAGAR, CUTTACK 753014
Ph. (0671) 2363014, 07852933988, 07852933989,7852933990

FOR OFFICIAL USE ONLY

Application No : ...............................

Category : ..............

University Registration No: ....................... Rank : ...................

1. COURSE : B. ARCH / M.ARCH
2. DISCIPLINE :
3. Name (In Capital Letters)
SURNAME

4. Father's Name

FIRST NAME

MIDDLE NAME

: _________________________________________________

5. Guardian's Name
: _________________________________________________
(If Father is not alive)
6. Date of Birth

: In Figures

(as recorded in HSC)

In Words
7. Nationality

: _______________

9. Mother Tongue : _______________

11. Sex

_____________________________________
8. Religion

: ________________

10.Blood Group

: ________________

: _______________

12. Whether belongs to any Reserved Category :

(SC / ST / OBC / PH / GREEN CARD / EX SERVICEMEN)
(Attach a Certificate from competent authority)
13. Occupation of Father / Guardian

: _________________________

14. Annual Family Income : ____________________

15. Address of Father / Guardian

ADDRESS FOR CORRESPONDENCE
NAME

C/O

AT

P.O.

DIST

PIN

PHONE (father / mother) :

EMAIL

(father / mother) :

16. Academic Records (Attach Attested Xerox copy of Certificates and Marksheets) :
Sl No Name of
Board /
Exam Passed University

Year of Max.
Passing Marks

Marks
% of
Secured Marks

Subject

17. If admitted, I propose to reside (Put mark in appropriate place)

In Hostel

With my Parent / Guardian

On Private Accomodation

18. I enclose herewith a Demand Draft / Banker's Cheque / Pay Order bearing No
__________ Dated ________ for Rs. _______________ drawn in favour of Ajay Binay
Institute of Technology, PMCA, Cuttack towards admission fees.
I hereby declare that the particulars given above are correct and true to the best
of my knowledge and belief.

Place : ______________
Date : ______________

Signature of Applicant

DECLARATION I
I do hereby undertake that I will obey the rules and regulations of the Institute. I will
not ask any refund of the fees paid in full or in part in any circumstances and If I do not
attend a single class or discontinue the course immediately after admission or even in the
middle of the session, I will obey every decision taken by the management regarding my
admission or rejection at any stage due to my negligence and inability. I also declare that I
have gone through the prospectus and have understood the course pattern and I am
taking admission in my own interest.

Place : ______________
Date : ______________

Signature of Applicant
Signature of the Father / Guardian

DECLARATION II
(For Candidates below the age of 18)
I declare that my son / daughter / ward ______________________________ will
abide by all the existing rules and regulations of the Institute after his / her admission into
the said Institute. I extend voluntarily the authority to the mangement of AJAY BINAY
INSTITUTE OF TECHNOLOGY, P.M.C.A. CUTTACK to take necessary actions in case of
any breach of rules worthy and appropriate for healthy academic prospects of my son /
daughter / ward.

Place : ______________
Date : ______________

Signature of the Father / Guardian