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STUDENT DATA
PROGRAM: BATCH: XIV Academic Period: 2023-2027
1. Personal Details:
1 Name (In Block Letters)
2 Anna University Reg. No Gender
3 DOB / / Place of Birth: Age
4 Passport No Blood Group
5 Aadhaar No PAN No
6 Mother Tongue: Nationality: Religion:
OC BC MBC/DNC BCM SC SCA ST
7 Community
8 Caste: Email id
Student Mobile No Facebook
9
LinkedIn Instagram id
10 Bank Name Branch
11 Account No. IFSC Code MICR Code:
12 Communication Address Permanent Address
Door No. Door No.
Street Street
City/Village City/Village
Taluk Taluk
District District
State State
Pin code Pin code
2. Educational Qualifications:
Details SSLC HSC / Diploma
Register No:
Name of the Institution:
City/Village
District
State
Country
Pin code
Medium & Board
Total Marks
Year of Passing:
Subject Marks Maths Science Maths Physics Chemistry
Percentage Cut-off Mark
Chennai Institute of Technology Document Date: 01-08-2023 Rev:5.0
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3. Identification Marks: -
1.
2.
4 Area of Interest:
Campus Placement
Govt. Sector Employment
Higher Studies
Entrepreneurship
Any other: ____________________
5. Extracurricular Activities (Area of Interest):
6. Future Plan (Describe in few words):
7. Sports/ other Talents:
[Link] Details:
Particulars Father Mother Guardian
Name:
Qualification:
Occupation:
Organization Name
Address:
Annual Income:
Email Id:
Mobile No:
9. Siblings, if any:
Particulars Brother / Sister - 1 Brother / Sister - 2
Name:
Qualification:
School / College/ Occupation:
Email Id:
Mobile No:
Chennai Institute of Technology Document Date: 01-08-2023 Rev:5.0
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10. Admission Details:
First Year Lateral Entry Transfer
Date of Joining:
MQ FG YES NO
Semester:
7.5 YES NO
GQ
PMSS YES NO
Yes No Boarding Point (if Yes) Route No.
Day scholar:
Yes No Room No (if Yes) Date of Relieving
Hosteller:
1. Scholarship details (Previously received) :
2. Membership: NSS/NCC/Professional Society :
3. Reason for choosing CIT/CITAR :
4. Name of the Referral :
5. Reason for choosing the Program :
6. Weight and Height metric : Height: cm Weight: kg
7. Food Allergy, if any :
8. Chronic diseases, if any :
11. Details of the Certificates:
Details of Original Certificates Signature
HSC /Diploma
Certificate SSLC TC Com. FG Income Migration Student Staff
+1 +2
Submitted
Received
Chennai Institute of Technology Document Date: 01-08-2023 Rev:5.0
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12. Parent/Guardian Photo:
Father’s Photo Mother’s Photo Guardian’s Photo
13. College Leaving Details:
1. Year of Completion 2. CGPA Obtained 3. Class Obtained
4. TC issued Date 5. T.C. No. 6. University Rank (if any):
14. Details of career chosen:
Chennai Institute of Technology Document Date: 01-08-2023 Rev:5.0