APP. NO.

: UG
ST. XAVIER'S COLLEGE 5150 AIDED
(AUTONOMOUS)
PALAYAMKOTTAI - 627 002
APPLICATION FORM 2019 – 2020 B.Sc SHIFT - I

Department No. :
(to be filled by the office) 19CSC Computer Science

Applicant Name CHINNA DURAI A

Date of Birth /Age 22/02/2002 / Blood Group B+
Sex MALE Mother Tongue TAMIL
Recent Colour
Nationality INDIAN Religion HINDU
Passport Size
Catholic NO Dalit Catholic NO Photo of the Candidate
Community SC Sub-Caste/Cer.No. PALLAN / 8723506 to be affixed

Native Place REDDIARPATTI District TIRUNELVELI

Annual
Parent’s Details Education Occupation
Income
Father Name ANANDARAJ 8TH COULI 42000
Mother Name MARIAMMAL 5TH COULI 42000
For Office Use
Guardian Name Relationship
Guardian Mobile
Parent Mobile No. 9843909427 /
No
Physically
NO If Yes Specify
Challenged
Son / Daughter of Ex-Serviceman of Tamilnadu Origin NO
Principal
Tamil origin From Andaman – Nicobar Islands? NO
Distinction in Sports NO NCC/NSS NO
Last Studied School Name K R GOVERNMENT HIGHER SECONDARY SCHOOL
Place REDDIARPATTI
Qualifying Examination Passed HSC Month & Year MARCH 2019
AADHAR NUMBER: 878930379258
HSC REGISTER NUMBER: 4042168
PAYMENT DETAIL: 4301
SUBJECTS

(1) LANGUAGE TAMIL 62 / 100

(2) LANGUAGE ENGLISH 45 / 100
(3) SUBJECT PHYSICS 45 / 100
(4) SUBJECT CHEMISTRY 60 / 100
(5) SUBJECT MATHEMATICS 35 / 100
(6) SUBJECT COMPUTER SCIENCE 56 / 100

TOTAL MARKS (3- 6) 196 / 400 (1 - 6) 303 / 600

PERCENTAGE (3 - 6) 49 % 100 (1 - 6) 50.5 % 100
 APP. NO.:
UG B.Sc SHIFT - I
5150 AIDED

Address for Communication (Present Address)

DOOR NUMBER 3/117 STREET AMMAN KOIL STREET
CITY REDDIARPATTI DISTRICT TIRUNELVELI
STATE TAMILNADU PIN CODE 627007
MOBILE
7540025572 E-MAIL ID cmdurai1934@gmail.com
NUMBER
Permanent Address( Fill with Blue or black ball point pen)
DOOR NUMBER STREET
CITY DISTRICT
STATE PIN CODE
MOBILE
E-MAIL ID
NUMBER
DECLARATION
I ................................................................................... understand that association with any
unlawful organisation during the course of my study in the College is forbidden. If selected for
admission, I promise to abide by the rules and regulations of the college. All the particulars
stated in this application are true to the best of my knowledge and belief.
Date:
Signature of the Applicant
UNDERTAKING BY PARENT OR GUARDIAN
If, my son / daughter ........................................................................................................ is
Admitted to the college, I undertake to pay regularly all his / her dues to the college till the
completion of his / her course of studies. I also undertake to be responsible for his / her
conduct, Progress in studies and attendance.
Date:
Signature of the Parent / Guardian
ONLY FOR CATHOLIC

I Rev. Fr. .........................................................................Certify that the applicant belongs to my

parish.
Signature of the Parish Priest
Please enclose the attested copies of the following certificates. Write the application
No. on top of each sheet:
1. Qualifying Examination Mark Sheet (HSC)
2. Community Certificate (BC / BCM / MBC / DNC / SC / ST /SCA)
3. A letter from the Parish Priest for Roman Catholics.
4. Certificate of proof to be produced by Differently Abled, Son or Daughter of EX.
SERVICEMAN and for Participation in SPORTS / NCC / NSS in school.