M. D.

University, Rohtak
Registration Form For
Odd semester (3rd /5th/7th) Session-2015-16

1. Name of
Student :
(IN BLOCK LETTERS)
2. Fathers Name
:
DD MM YEAR
3. Date of Birth :
4. Blood Group. ...
5. Adhaar Card No. : 6. Passport No. .
....
Photo in College
7. PAN No. : ..
Uniform
8. University Registration No. : ...
9. College Roll. No. : ..
...
10.Branch : .... 11. Semester. : .

12.Past Result :
Semest Result University Roll Result University Roll
Semester
er No. No.
1st 4th
2nd 5th
3rd 6th
13.Fee Deposited vide Receipt No .... Dated
.
(Photo copy of fee receipt to be enclosed)
14.Permanent Address:

..
..
Phone No. (With STD Code) Mobile No. (Parents)

15.Parents e-mail Address:
...
16.Present Address:
....

.
Phone No. (With STD Code) Mobile No. (Student)
..
17.Student e-mail Address:
..

UNDERTAKING
I hereby undertake to attend Lecture /Tutorial/Practical classes regularly and to
maintain more than 75% attendance in Class. I shall follow rules and regulations of
the college.

Date:

Signature of the student

REGISTRAR OFFICE
Shri/ Km College Roll No.
..
has been registered for B. Tech./ M. Tech Branch.. Semester

Date : .. Signature of
Registrar