B.

TECH
APPLICATION
FORM 2020
APPLICATION NO
: 20011082331

Personal Details
Nationality INDIAN
Have You Studied From India? YES
Name MS PONSRUTHI. M
Mobile Number +91-9940082334
Email ID SUGANYASM2002@GMAIL.COM
Alternate Email ID BABUGP42@GMAIL.COM
Date Of Birth 24/02/2003
Gender FEMALE
Community OBC/BC/MBC
Blood Group B+
Religion HINDUISM
Medium Of Instruction ENGLISH
Hostel Accommodation NO
Mother Tongue TAMIL
Where Do You See The Admission Advertisement NEWSPAPER
Are you Differently Abled ? NO

Preference Details
Specilization Test State
# Course Preference Campus Preference Test City Preference
Preference Preference
BIOMEDICAL BIOMEDICAL SRMIST, MAIN CAMPUS SRM IST, VADAPALANI
1 TAMIL NADU
ENGINEERING ENGINEERING (KATTANKULATHUR, CHENNAI) CAMPUS, CHENNAI
2
3

Family Details
Father Mother Guardian
Title MR MRS -
Name MUTHUKRISHNAN.P SUGANYA.M
Mobile Number +91-9444106654 +91-9940082334
Alternate Mobile Number -
Email Address BABUGP42@GMAIL.COM SUGANYASM2002@GMAIL.COM
Occupation OTHER (ADVOCATE) OTHER (TEACHER )

Address Details
NO 5 F3 LAND MARVEL KARPAGAMBAL RAJA STREET RAJA
Address Pin Code : 600028
ANNAMALAIPURAM
Country Name : INDIA State : TAMIL NADU District : CHENNAI Town/City: CHENNAI
Academic Details
Current Education Qualification Status : 12TH APPEARING
HSC Details (12th) :
Institute Name CHETTINAD VIDYASHRAM
Board CENTRAL BOARD OF SECONDARY EDUCATION (CBSE)
Mode of Study REGULAR/FORMAL
Marking Scheme
Percentage / CGPA
Year Of Passing
Registration No.
CHETTINAD HOUSE, RAJAH ANNAMALAIPURAM, MRC NAGAR, RAJA ANNAMALAI
Address Of School/College
PURAM, CHENNAI, TAMIL NADU 600028
NAD ID/Digilocker ID

Payment Details
Transaction ID 109886607784
Payment Date 27/06/2020
Mode Of Payment Debit Card

Declaration
I certify that the information submitted by me in support of this application is true to the best of my knowledge and belief. I understand that
in the event of any information being found false or incorrect, my admission is liable to be rejected/ cancelled at any stage of the program. I
undertake to abide by the disciplinary rules and regulations of the institute.

PONSRUTHI. M

27/06/2020