ANNA UNIVERSITY :: CHENNAI - 600 025

Application Form for Admission to B.E / B.Tech. / B.Arch. Degree Courses for the
seats reserved in University Departments of Anna University for Other State
Candidates for the academic year 2014 - 2015
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Date : 15/06/2014
1. Registration No. : 4255
2. Name : SUPRAKASH G
3. Name of the Parent / Guardian : SUBRATA G
4. Address for Communication : DR NO 8, BLOCK 3, ANANYA ASHOK
5.Photo of the
Candidate
: NO 5, WARREN ROAD, ALWARPET
: CHENNAI
: CHENNAI - 600004
: TAMIL NADU
Telephone Number : 4424660481 Mobile: 9840001298
Email ID : subrata,g@shriram.com
6. Date of Birth : 05-10-1996
7. Gender : Male
8. Religion : Hinduism
9. Category : General
10. Attested Photocopy of Community Certificate : NA
11. Kashmiri Migrant : No
12. Citizenship : Indian
13. Other State Name : West Bengal Code : 24
14. Permanent Residence Certificate enclosed : Yes
15. School of Study
Sl.
No
Class Year of
Passing
Name of the School District State
1 VIII Std. 2010 Ryan international
school
Thane Maharashtra
2 IX Std. 2011 Apeejay School Thane Maharashtra
3 X Std. 2012 Apeejay School Thane Maharashtra
4 XI Std. 2013 Chettinad Vidyashram Chennai Tamil Nadu
5 XII Std. 2014 Chettinad Vidyashram Chennai Tamil Nadu
6 Diploma. -- -- -- --

22. Counselling Centre : Anna University, Chennai


23. Choice of Campus and Branch : Candidate may choose at the time of Counselling


24. DD Particulars

16. Qualifying Examination : HSC CBSE(Central Board)
17. Name of the Board Exam : Central Board of Sec. Education
Board Examination Code No. : 2
18. Passed the Qualifying Examination : Yes
19. Details of Qualifying Examination Passed
Reg.No: 4600777 Month: 05 Year: 2014
20. Marks obtained in the HSC (Academic / Equivalent) Examination
Subjects Register
Number
Month and
Year
Maximum
Marks
Marks
Obtained
Percentage
Physics (P) 4600777 May-2014 100 93 93
Chemistry (C) 4600777 May-2014 100 93 93
Mathematics (M) 4600777 May-2014 100 95 95
Total (P + C + M) 300 281 93.66
Fourth Optional Subject
Computer Science
4600777 May-2014 100 98 98
21. NATA Registration No. : -- NATA Mark : --
Demand Draft No. : 93547
Demand Draft Date : 14/Jun/2014
Demand Draft Amount : Chennai
Name of the Bank : State bank of India
Bank Place : Chennai
DECLARATION BY THE APPLICANT

I, SUPRAKASH G Son / Daughter of SUBRATA G hereby solemnly declare that the information furnished and the
statements given in the application, coding sheet and the enclosures are true, correct and complete. I further declare that
should it be found otherwise, I will be liable to forfeit my seat and / or removal from the rolls of the Institution at whatever
stage of study I may be, besides making me liable for criminal prosecution. I am fully aware that as per the directions of the
Honble Supreme Court of India and Tamilnadu Prohibition of Ragging Act 1997, Ragging is an offence, as is banned in the
Institutions and anyone indulging in ragging is liable to be punished such as expulsion from the Institution and / or rigorous
imprisonment upto 3 years, and / or fine upto Rs. 25,000/-.

Place :

Date :

Signature of the Applicant

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DECLARATION BY THE PARENT / GUARDIAN

I, SUBRATA G Son / Daughter of ---------------------------------------------- hereby solemnly declare that I am fully aware of the
declaration made by the applicant, my Son / Daughter / Ward and I declare and bind myself on the same terms contained in
the above declaration. The statements and the information given are true, correct and complete. If it is found otherwise, the
applicant is liable to forfeit the seat and / or removal from the rolls of the Institution at whatever may be the stage of study,
besides making me liable for criminal prosecution. I am fully aware that as per the directions of the Honble Supreme Court
of India and Tamilnadu Prohibition of Ragging Act 1997, Ragging is an offence, as is banned in the Institutions and anyone
indulging in ragging is liable to be punished such as expulsion from the Institution and / or rigorous imprisonment upto 3
years, and / or fine upto RS. 25,000/-.

Place :

Date :

Signature of the Parent / Guardian

Note : Guardian can execute the above declaration, only if both the parents are not alive.

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