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<META content="Distance Learning programmes offered by BITS Pilani,India"
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height=76 src="DLPD-Admissions_files/bitslogo.gif" width=89 border=0></DIV>
<TABLE height=309 cellSpacing=0 cellPadding=0 width=300 align=right border=0>
<TBODY>
<TR>
<TD vAlign=top align=right width=760 height=309>
<DIV align=right>
<TABLE height=309 cellSpacing=0 cellPadding=5 width=595 border=0>
<TBODY>
<TR>
<TD class=small align=right height=12></TD></TR>
<TR>
<TD class=small align=right height=12>
<P align=left><B><FONT color=#660033>Retain one copy of this page
for your record and attach another copy with duly filled application
form.</FONT></B></P></TD></TR>
<TR>
<TD class=small align=right height=1>
<P align=left><B><FONT color=#0000ff>Application Number Allotted :
MSSS52047 </FONT></B></P></TD></TR>
<TR>
<TD class=normal_yazi align=left width=585 height=239>
<DIV align=left>
<TABLE cellSpacing=0 cellPadding=0 width=582 border=0>
<TBODY>
<TR>
<TD width=309 bgColor=#0059a1 colSpan=2 height=1><B><FONT
face=Verdana color=#ffffff size=1>Applicant's Personal
Details</FONT></B></TD>
<TD width=273 bgColor=#0059a1 colSpan=2 height=1>
<P align=right><U><B><FONT face=Verdana color=#ffffff
size=1>Monday, April 30, 2007(3:20:48
PM)</FONT></B></U></FONT></P></TD></TR>
<TR>
<TD width=126 height=27><FONT face=Verdana color=#0059a1
size=1>Programme</FONT></TD>
<TD width=456 colSpan=3 height=27><B><FONT face=Verdana
size=1>MS Software Systems</FONT></FONT></B></TD></TD></TR>
<TR>
<TD width=126 height=27><FONT face=Verdana color=#0059a1
size=1>Date of Birth</FONT></TD>
<TD width=456 colSpan=3 height=25><FONT face=Verdana
size=1><B>15/12/1971 </B></FONT><FONT face=Verdana
color=#0059a1
size=1>
Sex</FONT><FONT face=Verdana size=1><B> Male
</B></FONT></TD></TR>
<TR>
<TD width=126 height=27><FONT face=Verdana color=#0059a1
size=1>Your Name</FONT></TD>
<TD width=456 colSpan=3 height=27><B><FONT face=Verdana
size=1>MITHILESH KUMAR MISHRA</FONT></B></TD></TR>
<TR>
<TD width=126 height=26><FONT face=Verdana color=#0059a1
size=1>Father's Name</FONT></TD>
<TD width=187 height=26><B><FONT face=Verdana size=1>LATE SRI.
S.N. MISHRA</FONT></B></TD>
<TD width=109 height=26><FONT face=Verdana color=#0059a1
size=1>Mother's Name</FONT></TD>
<TD width=166 height=26><B><FONT face=Verdana size=1>SMT.
RAMKUWAR MISHRA</FONT></B></TD></TR>
<TR>
<TD width=126 height=26><FONT face=Verdana color=#0059a1
size=1>Address Line1</FONT></TD>
<TD width=187 height=26><B><FONT face=Verdana size=1>AF-2,
FACULTY HOSTEL</FONT></B></TD>
<TD width=109 height=26><FONT face=Verdana color=#0059a1
size=1>Address Line2</FONT></TD>
<TD width=166 height=26><B><FONT face=Verdana size=1>IIITA
CAMPUS</FONT></B></TD></TR>
<TR>
<TD width=126 height=26><FONT face=Verdana color=#0059a1
size=1>Address Line3</FONT></TD>
<TD width=187 height=26><B><FONT face=Verdana size=1>DEOGHAT,
JHALWA</FONT></B></TD>
<TD width=109 height=26><FONT face=Verdana color=#0059a1
size=1>City </FONT></TD>
<TD width=166 height=26><B><FONT face=Verdana
size=1>ALLAHABAD</FONT></B></TD></TR>
<TR>
<TD width=126 height=28><FONT face=Verdana color=#0059a1
size=1>Pin code </FONT></TD>
<TD width=187 height=28><B><FONT face=Verdana
size=1>211012</FONT></B></TD>
<TD width=109 height=28><FONT face=Verdana color=#0059a1
size=1>State </FONT></TD>
<TD width=187 height=28><B><FONT face=Verdana
size=1>UP</B></FONT></TD></TR>
<TR>
<TD width=126 height=28><FONT face=Verdana color=#0059a1
size=1>Country</FONT></TD>
<TD width=187 height=28><B><FONT face=Verdana
size=1>INDIA</FONT></B></TD>
<TD width=109 height=28><FONT face=Verdana color=#0059a1
size=1>other</FONT></TD>
<TD width=166 height=28><B><FONT face=Verdana
size=1></FONT></B></TD></TR>
<TR>
<TD width=126 height=25><FONT face=Verdana color=#0059a1
size=1>Phone Number (With STD Code)</FONT></TD>
<TD width=187 height=25><B><FONT face=Verdana
size=1>5322922153</FONT></B></TD>
<TD width=109 height=25>
<P align=left><FONT face=Verdana color=#0059a1
size=1>Mobile</FONT></P></TD>
<TD width=166 height=25><FONT face=Verdana
size=1><B>9450952584</B></FONT></TD></TR>
<TR>
<TD width=126 height=27><FONT face=Verdana color=#0059a1
size=1>Email</FONT></TD>
<TD width=456 colSpan=3
height=27><B>mmishra@iiita.ac.in</FONT></B></TD></TR></TBODY></TABLE>
<TABLE cellSpacing=0 cellPadding=0 width=600 border=0>
<TBODY>
<TR>
<TD width=600 bgColor=#0059a1>
<P align=left><B><FONT face=Verdana color=#ffffff
size=1>Applicant's Employment Details : </FONT></B></P></TD>
<TR>
<TD width=600 bgColor=#ffffff>
<P align=left><FONT face=Verdana color=#0059a1 size=1>Current
Employment Status :</FONT><FONT face=Verdana
size=1><B>Employed</B></FONT><FONT face=Verdana color=#0059a1
size=1> </FONT></P></TD>
<TR>
<TD width=600 bgColor=#ffffff><FONT face=Verdana color=#0059a1
size=1>Will your employer give consent for you to do the BITS
degree:</FONT><FONT face=Verdana size=1><B>Yes</B></FONT><FONT
face=Verdana color=#0059a1 size=1> </FONT></TD>
<TR>
<TD width=600 bgColor=#ffffff><FONT face=Verdana color=#0059a1
size=1>Will you be able to find a senior person in your
company to act as your mentor:</FONT><FONT face=Verdana
size=1><B>Yes</B></FONT><FONT face=Verdana color=#0059a1
size=1> </FONT></TD>
<TR>
<TD width=600>
<P align=left><FONT face=Verdana color=#0059a1 size=1>Name of
Employing Organization : </FONT><FONT face=Verdana
size=1><B>IIITA</B></FONT><FONT face=Verdana color=#0059a1
size=1> Location : </FONT><FONT face=Verdana
size=1><B>ALLAHABAD </B></FONT></P></TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1 size=1>Nature
of Employing Organization : </FONT><FONT face=Verdana
size=1><B>EDUCATIONAL</B></FONT><FONT face=Verdana
color=#0059a1 size=1> Other </FONT><FONT
face=Verdana size=1><B>SOFTWARE/IT</B></FONT></TD>
<TR>
<TD width=600>
<P align=left><FONT face=Verdana color=#ff0000
size=1>#</FONT><FONT face=Verdana color=#0059a1 size=1>Date of
Joining your present Organization : </FONT><FONT face=Verdana
size=1><B>29/09/2000</B></FONT><FONT face=Verdana
color=#0059a1 size=1> </FONT></P></TD>
<TR>
<TD width=600>
<P align=left><FONT face=Verdana color=#ff0000
size=1>#</FONT><FONT face=Verdana color=#0059a1 size=1>Total
Work Experience as on 11/05/2007 : </FONT><FONT
face=Verdana size=1><B>04 Year / 00 Month / 00
Days</B></FONT><FONT face=Verdana color=#0059a1 size=1>
</FONT></P></TD>
<TR>
<TD width=600><FONT face=Verdana color=#ff0000 size=1>#(As on
11/05/2007 to be counted only from the point of completing
BE/MSc or equivalent)</FONT></TD>
<TR>
<TD width=600 bgColor=#0059a1>
<P align=left><FONT face=Verdana color=#ffffff
size=1><B>Applicant's Educational Details : </B></FONT></P></TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1 size=1>Have you
ever been a student of BITS, Pilani? </FONT><FONT face=Verdana
size=1><B></B></FONT><FONT face=Verdana color=#0059a1
size=1> </FONT></TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1 size=1>If yes,
Please write your Identification (ID) Number : </FONT><FONT
face=Verdana size=1><B></B></FONT></TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1 size=1>Are you
currently enrolled for pursuing some degree or diploma from
any other University: </FONT><FONT face=Verdana
size=1><B>No</B></FONT></TD>
<TR>
<TD width=600> </TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1 size=1>Do you
have B.E.(Hons.), M.Sc.(Hons.) or equivalent from a university
: </FONT><FONT face=Verdana size=1><B>Yes</B></FONT><FONT
face=Verdana color=#0059a1 size=1> </FONT></TD>
<TR>
<TD width=600><FONT face=Verdana color=#ff0000 size=1>(3 year
BSc / BCA etc not eligible for MS)</FONT></TD>
<TR>
<TD width=600>
<P align=left><FONT face=Verdana color=#0059a1 size=1>If Yes,
Name of the University : </FONT><FONT face=Verdana
size=1><B>SIKKIM MANIPAL UNIVERSITY</B></FONT><FONT
face=Verdana color=#0059a1 size=1> </FONT></P></TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1
size=1> Name of the
Degree : </FONT><FONT face=Verdana
size=1><B>M.SC.</B></FONT><FONT face=Verdana color=#0059a1
size=1> </FONT></TD>
<TR>
<TD width=600><FONT face=Verdana color=#0059a1
size=1> Branch of the
Degree : </FONT><FONT face=Verdana
size=1><B>IT</B></FONT><FONT face=Verdana color=#0059a1
size=1> </FONT></TD>
<TR>
<TD width=600>
<P align=left><FONT face=Verdana color=#0059a1
size=1>
Year of Passing the Degree : </FONT><FONT face=Verdana
size=1><B>2003</B></FONT><FONT face=Verdana color=#0059a1
size=1> % obtained in Degree : </FONT><FONT
face=Verdana size=1><B>71 </B></FONT></P></TD>
<TR>
<TD width=600 bgColor=#0059a1>
<P align=left><FONT face=Verdana color=#ffffff
size=1><B>.</B></FONT></P></TD>
<TR>
<TD width=600>
<P align=left>
<P align=left><FONT face=Verdana size=1><B>The details
submitted above are true to the best of my knowledge.</B>
</FONT></P></TD></TR>
<TR>
<TD width=600>
<P align=right>Signature of the
applicant</P></TD></TR></TBODY></TABLE></DIV></FORM></TD></TR>
<TR>
<TD class=small align=left height=22>
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