Last Date of Receipt

LAST DATE OF RECEIPT: 20 JUNE, 2015 Application No.

BIRLA INSTITUTE OF TECHNOLOGY & SCIENCE

PILANI, RAJASTHAN - 333 031

First Semester 2015-2016

Application for Admission to Bachlor of Optometry (B.Optom.)

Note: Please read the instructions given at the end carefully before filling in this application form.

SECTION 1: PERSONAL INFORMATION & EDUCATIONAL BACKGROUND

Full Name:

(in Capital Letters as

it appears in Class XII Exam Marksheet)

Affix unattested

Passport Size Photograph

2. 2.1 Date of Birth

Date Month Year

2.2 Age

Years Months

3. Sex: (Enter 'M' if Male & 'F" if Female)

4. Do you belong to Scheduled caste or Scheduled tribe? [Y/N]

5. Nationality ('I' if Indian, 'O' if any other)

If 'O' to above, specify

6. (a) Father's Name:

(b) Mother's Name:

7. Marital Status (fill in 'M' if Married, 'S' if Single)

8. Do you have access to Internet ? [Y/N]

9. Email address:

10. Contact details

Phone (Residence): STD Code: Number:

Mobile Phone: Number:

FAX Number: STD Code: Number:

11. Address for Correspondence (in Capital Letters):

Line 1 of address: ______

Line 2 of address: ______

City State

Pin / Zip Code Country

12. Permanent Home Address (in Capital Letters)

Line 1 of address: ______

Line 2 of address: ______

City State

Pin / Zip Code Country

13. Name of School last attended with city / location:

14. Fill in your educational details from School Leaving Certificate onwards in chronological order:

Name of the Examination / Subjects / Board / University / Year of passing / Total Marks Obtained / Maximum Marks / Final %age of Marks* / Div
Class X or equivalent (specify)
Class XII or equivalent (specify)
Any other
(specify)

* As calculated for declaring result and award of Division by your Board / University. If marks are not awarded give Cumulative Grade Point Average or its equivalent. Also ensure that when entering Class XII marks, only Class XII marks are entered and you are not to include Class XI marks.

15. If you have any gap in time from the latest Board / University Examination mentioned above to the time of this application, explain this gap with related documents. Suppression of any fact in this connection will render the applicant ineligible for admission. In deciding the admission, the Institute will be guided by the latest performance.

16. Marks obtained in Class XII Examination. (Do not include Class XI Marks). If you have done Botany – Zoology then combine them as Biology for calculating your PCB and also write your marks in Botany Zoology in the empty rows provided in table below:

Subject / Marks obtained / Maximum Marks
Physics (P) /
Chemistry (C)
Mathematics (M)
Biology (B)
English

17. Programme Preference Details: Out of the TWO programmes given below, indicate your first preference by writing 1 in the box against the corresponding programme and your second preference by writing 2 in the box against the corresponding programme and so on. In case you are NOT interested in a particular programme please mark X against that programme. Please note that, this one form is enough to apply for the following two programmes and you should not fill separate forms for each programme.

Bachelor of Optometry (B.Optom) at Sankara Nethralaya, Chennai

Bachelor of Optometry (B.Optom) at LV Prasad Eye Institute, Hyderabad

18. Declaration by the Applicant

I have carefully read the programme details and the instructions given in this application form and hereby declare that all the information given and statements made in various sections and parts of this Application Form and enclosures are true to the best of my knowledge. I agree to the condition that if any information or statement were found to be wrong, my admission to BITS would automatically be cancelled. If admitted, I promise to abide by the Rules and Regulations in force or those that may hereafter be made by the Institute and I shall do nothing either inside or outside the Institute which will interfere with its orderly working and discipline. I promise to be regular in the study schedule and in appearing in the examinations at allotted centre. In the case that I myself will be paying my fees / dues, I affirm that I will regularly pay all fees / dues to the Institute during my programme. Further, in all matters concerning the Institute and myself the decision of BITS Vice-Chancellor shall be binding on me.

Place Signature

Date Name

19. Declaration by Parent / Guardian

I do solemnly affirm that I shall be responsible for the discipline and conduct of my son / daughter / ward and will pay regularly all fees / dues to the Institute in time during his / her programme.

Place Signature

Date Name

SECTION 2: COMPUTER DATA SHEET

SECTION 1: PERSONAL INFORMATION & EDUCATIONAL BACKGROUND

Full Name:

(in Capital Letters as

it appears in Class XII Exam Marksheet)

Affix unattested

Passport Size Photograph

2. 2.1 Date of Birth

Date Month Year

2.3 Age

Years Months

3. Sex: (Enter 'M' if Male & 'F" if Female)

4. Do you belong to Scheduled caste or Scheduled tribe? [Y/N]

5. Nationality ('I' if Indian, 'O' if any other)

If 'O' to above, specify

7. (a) Father's Name:

7. Marital Status (fill in 'M' if Married, 'S' if Single)

8. Do you have access to Internet ? [Y/N]

9. Email address:

10. Contact details

Phone (Residence): STD Code: Number:

Mobile Phone: Number:

FAX Number: STD Code: Number:

11. Address for Correspondence (in Capital Letters):

Line 1 of address: ______

Line 2 of address: ______

City State

Pin / Zip Code Country

12. Permanent Home Address (in Capital Letters)

Line 1 of address: ______

Line 2 of address: ______

City State

Pin / Zip Code Country

13. Name of School last attended with city / location:

14. Fill in your educational details from School Leaving Certificate onwards in chronological order:

Subject / Marks obtained / Maximum Marks
Physics (P) /
Chemistry (C)
Mathematics (M)
Biology (B)
English

Bachelor of Optometry (B.Optom) at Sankara Nethralaya, Chennai

Bachelor of Optometry (B.Optom) at LV Prasad Eye Institute, Hyderabad

CHECKLIST FOR ENCLOSURES / ATTACHMENTS

Important: Please ensure that you have enclosed the following documents / Information without which your application will be considered as incomplete and rejected. You must also ensure that the enclosures are appended in the same order as given below. Please Tick (ü ) against all those items / documents you have enclosed.

1. Demand Draft for the requisite processing fee. DD No.: ______Dated ______for

Rs. 1500/- drawn in favour of BITS, Pilani.

Copy of ICICI Bank Challan Branch Transaction ID:______Dated______

Copy of Net Banking Payment Receipt Transaction ID:______Dated______

Copy of Credit Card Payment Receipt Transaction ID:______Dated______

2. One Attested photocopy of Xth pass / Matriculation / Secondary School Leaving Certificate

3. One Attested photocopy of SC / ST certificate by competent authority

4. One Attested photocopy of XII standard marksheet issued by your board

5. One Attested copy of any other documents like Gazette notification for correct name purpose

Specify

6. Affix three unattested passport size copies of your Photographs in space below.

For Office Use Only: Enclosure verification

Name Signature Date

BIRLA INSTITUTE OF TECHNOLOGY & SCIENCE, PILANI

http://www.bits-pilani.ac.in

INSTRUCTIONS TO APPLICANTS

Application No.

1. You must note down your application number and detach this instruction sheet and retain for your own reference.

2. Please note down the unique application number assigned to the application form when you downloaded the form from the website. This application number must be mentioned clearly in the space provided on the top right corner of each page of the application form.

3. The number of your Application Form is unique. In all subsequent correspondence with the Institute until admissions are finalized make sure that you quote the application number. Failure to do this may make it difficult to connect your correspondence with your Application Form and may cause results to your disadvantage. The Institute cannot take responsibility for any negligence on your part.

4. Before filling in this Application Form be sure to carefully read Programme details from the Institute website.

5. All entries should be filled in neatly and legibly (in block letters).

6. Enter your name as given in your class XII Examination marksheet / pass certificate issued by your Board. In the records of our Institute only this name will be incorporated. Pass certificates given by school / college will not be sufficient. If your name in our records is to be different from the name as given in your marksheet / pass certificate issued by your Board, then you must enclose a copy of the supporting documents such as gazette notification etc.

7. The applicant must ensure that an unattested passport size photograph is duly affixed on the first page of the application form and Checklist page. Avoid stapling the photograph and affix it with good quality glue only.

8. Enter your date of birth as given in your matriculation / Secondary School Leaving Certificate or equivalent.

9. Whenever a code letter needs to be entered in a box, specific instructions have been given with the item. However in the case of items with (Y / N), "Y" stands for "Yes" and "N" stands for "No": Enter the appropriate letters (either Y or N) as per instructions given in the specific item.

10. Access to email would be highly desired. You are strongly urged to make efforts to obtain access to email facilities. When writing your email address in the application form you must be careful about capital / small letters, underscore, hyphen, etc.

11. The applicant should take utmost care when filling the Address for Communication and Permanent Home Address.

12. All the certificates (photocopies) and other attachments / enclosures should be submitted together with application. Such attachments should be properly fastened at the end of application form with a tag or by stapling. Mark all such attachments on the checklist provided at the end of application. Make sure that all enclosures are appended in the same order as in the checklist. On the top right hand corner of each of your enclosure you must write your Application Number. All enclosure documents should be given in only A4 Size Paper, which means that you must enlarge or reduce your document size appropriately.

13. Please check the demand draft for the requisite application processing fee carefully and ensure that it is correct and complete in all aspects such as date, drawee name, bank manager signature, name and code of issuing bank branch and drawee bank branch, amount in words and figures. Please ensure that the application number and applicant’s name is written clearly on the backside of the demand draft.

14. Applicant must ensure that the duly filledup application form reaches Pilani by the deadline specified failing which the application will not be considered for admissions.

15. Incomplete Applications will be summarily rejected.

16. You are advised to retain a photocopy of the duly filled in application form for your own record.

17. All admission related queries by email should be addressed to along with the name of the candidate and application number as given on the top of the Instructions to Applicants page.

18. The applicant is strongly advised to check the shortlist status (after the stipulated deadline for submitting filled in forms) from our website http://www.bits-pilani.ac.in/optometry

19. The offering of any of these programmes is subject to availability of viable number of suitable candidates.

20. This application is valid only for the semester of admission for which the deadline is specified in the first page of this application form. This form will not be valid for a future semester of admission.

1 of 9