POORNIMA

COLLEGE OF ENGINEERING

POORNIMA S3
COLLEGE OF ENGINEERING
Application Form for Registration to II / III / IV Year
(Provisional Admission subject to passing of previous examination as per University Rules of promotion)
PCE
Campus : _______Course: BTech
_______________________ Branch: ______________________
AIDS
4th
Year : _________________ 7th
Semester : _______________________________
Paste/ Staple
(A) PERSONAL INFORMATION: Passport size
1. Kusum Nebhwani
Name ______________________________________________________________ Photograph
2. Father’s Name:_______________________________________________________
Kishor Nebhwani

3. Reg. No.:_____________________
PCE21AD029 21EPCADF40P030
Enrol. No.__________________ A+
Blood Group:_______________
4. Category: General YES SC ST OBC
5. Urban
Belonging to Rural/Urban Area _____________ Sindhi
Caste:_____________ Jaipur
Birth Place__________________
6. Parent’s Present Address : Local Guardian’s Residential Address:
________________________________________
Plot 12A Govind Nagar west amer road ________________________________________
Plot 12A Govind Nagar west amer road
________________________________________ ________________________________________
Jaipur Jaipur
_______________Distt._____________________ ________________________________________
302002 Rajasthan
Pin Code:___________State:________________ 302002
Pin Code:________________________________
Mobile_________________________________
8209993104 6376451550
Mobile_________________________________
Please inform immediately if above addresses are changed.
(B) DETAILS OF FEES:
Due Date Amount DD No. Bank Rec. No. &
Date

Fees

Other Charges

Late Payment Fine applicable @ 50/- per day for violation of above dates.
1. Mode of Transport (√ as applicable): Own Vehicle yes Public Transport College Transport
2. Whether Hosteller or Day Scholar (Specify):________________________________________________
If day scholar then (√
as applicable): Living with Parent's yes Rented Room
3. Hobbies: ____________________________________________________________________________
4. Sports of your interest (Indoor): __________________________ (Outdoor):_______________________
(C) DETAILS OF SUBJECT(S) / PAPER(S) THEORY & PRACTICAL) NOT CLEARED:
I Year II Year III Year IV Year

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 POORNIMA
COLLEGE OF ENGINEERING

POORNIMA S3
COLLEGE OF ENGINEERING
Application Form for Registration to II / III / IV Year
(D) DETAILS OF PARENT’S:
1. Kishor Nebhwani
Father’s Name: ___________________________________ -
Qualification: ________________________
Occupation: ____________
Business Department / Company: ___________________
Textile Designation____________
Mobile: _______________________________
6376451550 [email protected]
E-mail ID_____________________________________
2. Mother’s Name: __________________________________
Ritu Nebhwani Qualification: ________________________
Bcom
Occupation: Housemaker
____________ Department / Company: ___________________, Designation____________
8209993104
Mobile: _______________________________ E-mail ID_____________________________________
3. Father’s Annual Income Rs._________________
2,40000 2,40000
Father’s Annual Income Rs.___________________
4. Present residential address of the student if different from parent’s present address (in case of rented room):
___________________________________________________________________________________
(E) DECLARATION & AGREEMENT BY THE STUDENT:-
Kusum Nebhwani AIDS
I, _________________________ Kishor Nebhwani
S/o / D/o Sh.____________________ Branch: _____________declare;
(i) That I have read all the rules governing readmission in PF and filled in the application form after thoroughly
understanding these rules.
(ii) That the information filled in by me in the application form is true to the best of my knowledge and belief.
(iii) That I have not been debarred from appearing in any examination held by any Government constituted or Statutory
Examination Authority in India or abroad.
(iv) That I shall not indulge in any form of ragging or indiscipline and shall strictly abide the by the rules of conduct.
(v) I am aware of University rule of fulfilling 75% attendance to be able to apply for the university examination. I
appreciate this rule and agree to comply with the same for my successful engineering career.
I Agree
(i) That the admission granted to me is on a purely provisional basis subject to confirmation by PF as per rules.
(ii) To conform to the rules and regulation at present in force or that may hereafter be made for the governance of PF and
Hostel. I further undertake that so long as I am a student of the PF I will do nothing, either inside or outside the campus
and Hostel that will interfere with their orderly governance and discipline.
(iii) That I shall not involve myself if fighting / quarrelling with other students (Junior/ Senior or Outsiders). I further
undertake that I shall not participate/ involve myself in any manner, in any manner, in any form of ragging or
indiscipline & shall strictly abide by the rules of conduct.
(iv) That the director of institute will have full liberty to expel me from the institute or Hostel for any infringement of the
above undertaking.
(v) To execute an agreement as prescribed by the management at the time of admission to the PFand Hostel.
(vi) That I will not be allowed to fill-up the university examination if my attendance is less than 75% (the minimum
threshold level required to appear in university exam) of the total classes held during current semesters/session.

Signature of Student with Date

FOR OFFICE USE ONLY

Form Checked & Approved by Tutor – (Name and Signature with date)

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