BITS Pilani Dubai Campus

Birla Institute of Technology & Science, Pilani Dubai Campus

Application for Admission to Higher Degree Programme Academic Year 2012-13
Application No.
(for office use only)

Part - I 1. Name:

PERSONAL INFORMATION
(as given in qualifying examination certificate)

2. Sex:

Male

Female

3. Date of Birth:
(dd/mm/yyyy)

4. Nationality: 6. Passport No.: 7. Do you hold a U.A.E. Resident Visa? Yes:

5. Blood Group: Valid up to:

(dd/mm/yyyy)

Photo

No:

If yes, Give: Visa No. ______________ Valid up to:_____________ If No, Tick if you require Student Visa 8. Address for Correspondence: Phone: Mobile: City: 9. Fathers Name: 10. Mothers Name: 11. Emergency contact: Part - II Phone: Country: Email: Mobile: Mobile: Email:

ACADEMIC RECORDS
Board/ University /Institute Duration of the Programme Year of Completion Percentage of aggregate marks / CGPA

Qualification (specify specialization if any) 10th Grade or Equivalent 12th Grade or Equivalent B.E. / B.Tech. / _____

If you have ever been on the rolls of BITS, supply the latest ID. No: ____________________

Part - III

EMPLOYMENT DETAILS
Period Name & Address of the Organisation Designation

1. Employment record ( list most recent first)

From To

Total experience in completed no. of years: ______ years (mention experience beyond the qualifying degree).

2. Information on current employment Place of work: ______________________________________________________ ( Location & City) Working hours: From: ________________________to ______________________ Weekend holidays: __________________________________________________ (Specify days)

Indicate preferences for admission to various programmes: [Mark 1, 2, 3,.. for order of preference against each of the programmes listed below. If you are not interested in a programme, put a cross (X)] M.E. Software Systems M.E. Design Engineering M.E. Biotechnology M.E. Microelectronics Part V OTHER DETAILS If any member of your family studied or is studying at BITS Pilani, Dubai Campus, give details: Name Relation ID NO./Year of Admission Master of Business Administration (M.B.A.) In two streams: Engineering & Technology Management IT Enabled Services Management

Part VI DECLARATION BY THE APPLICANT

I have read the Admission Instructions & shall abide by all the conditions laid therein. I further hereby declare that all the information given and statements made in this application and also its accompanying attachments and enclosures are true to the best of my knowledge. I agree to the condition that if any information or statement is found to be incorrect, my admission will automatically be cancelled. If admitted, I promise to abide by the rules and regulations in force or those that may hereafter be made for the administration of the Institution and I shall do nothing either inside or outside the Institution which will interfere with its orderly working and discipline. In all matters concerning me and the Institution, its hostels, etc. the decision of the Vice-Chancellor shall be binding on me.

Place & Date _____________________________

Check-List of Enclosures Required. Tick () the boxes.

Signature____________________________

Photo copy of 10th Class Certificate / mark sheet. Photo copy of the B.E. / B.Tech. or equivalent degree. Photo copy of the transcript or mark sheets of all semesters of the B.E. / B.Tech. or equivalent examination. A 250-word statement of purpose describing what you propose to achieve by doing this programme and your ultimate goal. Three letters of recommendation with at least one letter from an academic source. Details of awards like Merit Scholarships, Gold medal, N.S.T.S., N.T.S., etc, received by you. Details of the courses/projects done by you in the area of computer and software, If you have given preference to
M.E. Software Systems.

FOR OFFICE USE

Application Fee Paid Programme Fee Paid

Yes Yes

No No

Receipt No. _____________ Dt._________________ Receipt No. _____________ Dt._________________

Admitted to _____________________________________________ ID. NO. ________________________ Date: _____________________ Signature of Dean ________________________