KIIT UNIVERSITY

BHUBANESWAR, ODISHA, INDIA

KIITEE - 2011
APPLICATION FORM
1. Candidate’s Name
as given in Class X Certification
2. Father’s Name Paste recent Passport
as given in Class X Certification size Photograph
Must indicate clearly
3. Mother’s Name the name of the
candidate
4. Date of Birth (4 cm x 5 cm size)
(Dont staple)
5. Sex Male Female

6. Nationality Indian

7. Category Reservation General Schedule Caste Schedule Tribe Physically Handicapped

Odisha State Candidates Yes No

8. Course Applied
9. Choice of Entrance Subject
(Dual Degree Bio Tech)
10. Choice of Entrance Subject
(M. Tech)
11. Centre Option 1
Centre Option 2
12. Qualification Details
Qualification (Tick any One Option) 10+2 Diploma Graduation Post-Graduation Others

Qualifying Exam Status Passed Appearing

% Marks in PCM (for B.Tech /

Dual Degree)
% Marks in PCB (for MBBS /
BDS / Dual Degree Bio Tech)
% Marks in Aggregate (for others)
Passing Year
Class X Board Roll No
Class X Board Name
Class X Passing Year

13. Communication Address

Line 1

Line 2

Line 3

City

State Pincode

Phone No. (with STD Code) Mobile No.

14. Email. Id
15. Additional Information for M.Tech / Ph.D / PDF only
Branch / Stream of Qualifying Examination

Research Area Applied for with

Specilisation/department (Ph.D/PDF)
Sponsored

Gate Score (in 0000.00 format)

Experience

Declaration:
I hereby undertake that the information given through this Application form are true and correct to the best of
my Knowledge.

Signature of the Father / Signature of the Candidate

Mother / Guardian Date:

Check List: Yes No

1. Xerox copies of Class X marksheet/certificate enclosed.
2. Two passport size photographs (must indicate clearly the name of the
candidate) pasted in the registration form in the boxes provided.
3. Signed by both Candidate and Guardian.
5. If you are applying for Ph.D, PDF then enclose copies of all academic
certificates and mark sheet starting from X Class.

Paste recent Passport

size Photograph
Must indicate clearly
the name of the
candidate

(4 cm x 5 cm size)
(Dont staple)
Signature of the Candidate