B K Birla Institute of Engineering & Technology
BKBIET Campus, PILANI, Rajasthan - 333 031
Application cum Registration Form
Lateral Entry in Engineering Program (LEEP-2022)
CS
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CS(Data Science)
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Electrical
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Electronics & Communication
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Information Technology
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Mechanical
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Artificial Intelligence
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Full Name of the Candidate
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Father's Name
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Mother's Name
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Category: (GEN / OBC / SC / ST / Minority / Others)
---Choose Category---
GEN
OBC
SC
ST
Minority
Others
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Category II: (Ex-S / KM / PMSS / PWD / NRI / Others)
---Choose Category---
Ex-S
KM
PMSS
PWD
NRI
Others
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Occupation and Annual Income of Father / Guardian
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Aadhar Number
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Address
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Post Office
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City
*
District
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PIN
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State
---Select State---
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Dadra and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttaranchal
Uttar Pradesh
West Bengal
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Mobile No
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Email
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Resident of Pilani
Yes
No
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Studied at any Birla School
Yes
No
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State of Domicile
---Select State of Domicile---
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Dadra and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttaranchal
Uttar Pradesh
West Bengal
*
Branch Opted For: [Choose 1/2/3/4/5/0 from the list-box below (1 indicates Highest, 5 indicates Lowest and 0 indicates No Preference)]
Computer Science
---Select Preference---
1
2
3
4
5
0
CS (Data Science)
---Select Preference---
1
2
3
4
5
0
Electrical
---Select Preference---
1
2
3
4
5
0
Electronics & Communication
---Select Preference---
1
2
3
4
5
0
Information Technology
---Select Preference---
1
2
3
4
5
0
Artificial Intelligence
---Select Preference---
1
2
3
4
5
0
Mechanical
---Select Preference---
1
2
3
4
5
0
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Date of Birth as entered in Secondary Certificate:
---Month---
January
Febuary
March
April
May
June
July
August
September
October
November
December
---Day---
1
2
3
4
5
6
7
8
9
10
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12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
---Year---
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
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Percentage / CGPA of Class 10th
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Percentage / CGPA of Class 12th (If not appeared, please put "0")
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Percentage of Engineering Diploma / B.Sc
Passport Size Photo
Scanned Signature
