GOVERNMENT OF KERALA DEPARTMENT OF TECHNICAL EDUCATION

Application to Polytechnic College Admission 2012-13

Application No.: Page :

131611
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Date of online entry: 22/05/2012 Fee to be remitted: Rs. 100/- x 3 = Rs. 300/-

at Polytechnic College Districts chosen for Admission Name of the District where the candidate seeks admission: Basic Details 1. Name of the Candidate: 2. Name of Father/Mother/ Guardian 4. Communication Address: JACOB CYRIAC BEENA CYRIAC 3. Relationship with Applicant: Mother 1) Kottayam 2) Idukki 3) Ernakulam

NEDUVELIL HOUSE ELANJI P.O ERNAKULAM DIST

PIN CODE: 5. Mobile No.: 7. Gender: 9.Nationality: 11.Annual Family Income: Community Details 1.Are you eligible for reservation under inter-caste married 2.Whether OEC: Other Reservation Details 1.Have you passed ITI examination: 3.Have you passed VHSE: 5.Are you a person with disability: 6.Special Reservations: Academic Details 1.Name of Examination: 3.Year of Passing: 5.No. of Chances Taken: CBSE 2010 1 No No No No No 8281028134 Male Indian 80000

686665 6. E-mail: 8. Date of Birth: 10. Native District: kunjakochan@gmail.com 16/12/1993 Ernakulam

2.Community

Other

No

2.ITI Trade: 4.VHSE Trade:

2.No. of Subjects: 4.Exam Register No.:

5 4137254

Application No.: Page : 6.Mark List Sl. No. 1 2 3 4 5 Option Details Option No. District: 1 2 3 4 5 District: 1 2 3 District: 1 2 3 Polytechnic College Kottayam Government Polytechnic College, Pala Government Polytechnic College, Pala Government Polytechnic College, Kaduthuruthy Government Polytechnic College, Kaduthuruthy Government Polytechnic College, Kottayam Idukki Government Polytechnic College, Muttom Government Polytechnic College, Muttom Government Polytechnic College, Muttom Ernakulam Government Polytechnic College, Kothamangalam Government Polytechnic College, Kalamassery Government Polytechnic College, Kothamangalam Course Name Subject Name ENGLISH COMM. MAL/SAN/HIN/OTR MATHEMATICS SCIENCE SOCIAL SCIENCE Grade C2 B1 C1 B2 B1

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Computer Engineering Electronics Engineering Electronics Engineering Computer Engineering Mechanical Engineering

Mechanical Engineering Computer Engineering Electronics Engineering

Mechanical Engineering Mechanical Engineering Electronics Engineering

Certificate Details Sl No. Name of Certificate 1 2 SSLC/THSLC or equivalent Certificate Income Certificate from Village Officer. Cert.No. 0427844 210/2012 Issue Date 28/05/2010 01/02/2012 Authority CENTRAL BOARD OF SECONDARY VILLAGE OFFICER ELANJI

Application No.: Page :

131611
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Declaration
1. I hereby declare that, I have read the various clauses in the Prospectus for Admission to Polytechnic Colleges 2012 - 2013 and the instructions carefully and I agree to abide by them. 2. I also declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief and that in the event of any information being found false or incorrect or ineligibility being detected before or after the admission, action can be taken against me.

Signature of the Parent/Guardian Place: Date:

Signature of the Applicant

Application No.: Page :

131611
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Receipt

Received from JACOB CYRIAC, S/D/W/o Sri. BEENA CYRIAC, application for Polytechnic Admission (Application No. 131611) on ........................ at ............................................................... Polytechnic College,............................................. an amount of Rs. Rs. 100/- x 3 = Rs. 300/- is received as the application fee. The Application is registered with Registration No................

Seal of Receiving Polytechnic College

Principal

Receipt

Received from JACOB CYRIAC, S/D/W/o Sri. BEENA CYRIAC, application for Polytechnic Admission (Application No. 131611) on ........................ at ............................................................... Polytechnic College,............................................. an amount of Rs. Rs. 100/- x 3 = Rs. 300/- is received as the application fee. The Application is registered with Registration No................

Seal of Receiving Polytechnic College

Principal