INSTITUTE OF ENGINEERING & TECHNOLOGY, LUCKNOW

(An Autonomous Constitutent Institute of Dr. A.P.J.Abdul Kalam Technical University)

STUDENT PROVISIONAL REGISTRATION FORM (2017-2018)

Printed On :26-Jul-2017
Registered On :26-Jul-2017

Branch : B. Tech. Chemical Engineering

Semester : 7

Roll No. : 1405213022

Name : KAMESH KUMAR

Father's Name : ANIL KUMAR

Mother's Name : SAVITA DEVI

DOB : 21/02/1997

Gender : Male

Category : GEN

Sub Category : Fee Waiver

Email Address : KAMESHTRIPATHI89@GMAIL.COM

Mobile No. : 9170678298

Father's/Guardian Mobile. : 9451618252

Father's/Guardian E-mail. :

Correspondance Address : ROOM NO-319, VISHWESARAIYYA A-BLOCK HOSTEL,IET

LUCKNOW

Permanent Address : WARD NO.-16,

AKHADA MOHAL,
ROBERTSGANJ, SONEBHADRA

Father's/Local Guardian Address : dharmsala road,Robertsganj

Hosteler Request : NO

Paid Amount(Rs.) :

Declaration:I undertake that the information submitted is true to the best of my knowledge and belief. I shall bear
the consequences if any of them are found to be wrong.
Undertaking by the Student:I will attend all the classes from the opening day of the Institute and I will be regular
and punctual to all the classes i.e (Theory/Practical) and i am aware that if I dont secure attendance more than
75% I shall be detained and not allowed to appear for the Term End Examination.

Student (Seal and Signature) (Seal and Signature) (Seal and Signature)

Signature Faculty Advisor Head of Department Dean Academic

Note : You have to submit this print out to the Institute for validating your Registration