GOVERNMENT OF KERALADEPARTMENT OF TECHNICAL EDUCATION

Application to Polytechnic College Diploma (Evening) Admission 2014-15Application No.: 124854Page : 1 of 3

Date of online entry: 05/07/2014

Fee to be remitted: Rs. 200/-

at Polytechnic College

Polytechnic College, Application Type and Programmes chosen for Admission

1. Name of the Polytechnic S.S.M. Polytechnic College, TirurCollege where candidateseeks admission:

2. Application Type : General

3. Diploma Programmes which candidate seeks admission:

1 Electronics Engineering

2 Automobile Engineering

Basic Details

1. Name of the Candidate: VISHNUDAS O

2. Name of Father/Mother/ RAGHAVAN O 3. Relationship with Applicant: Father Guardian

4. Communication Address:ozhukunnath House, Ozhur, Malappuram Dist

PIN CODE: 676307

5. Mobile No.: 9562813654 6. E-mail:

7. Gender: Male 8. Date of Birth: 16/10/1995

9.Nationality: Indian 10. Native District: Malappuram

11.Annual Family Income: 24000

Community Details

1.Are you eligible for No 2.Community Ezhava/Thiyya reservation under inter-caste married

2.Whether OEC: No

Other Reservation Details

1.Have you passed ITI: No 2.ITI Trade:

3.Have you passed VHSE: No 4.VHSE Trade:

5.Have you passed KGCE: No 6.KGCE Trade:

Academic Details

1.Name of Examination: SSLC 2.No. of Subjects: 10

3.Year of Passing: 2011 4.Exam Register No.: 423521

5.No. of Chances Taken: 1

Application No.: 124854Page : 2 of 3

6.Mark List

Sl. No. Subject Name Grade

1 LANG I B+

2 LANG II A+

3 ENGLISH A

4 HINDI A+

5 SOCIAL C+

6 PHYSICS A+

7 CHEMISTRY B

8 BIOLOGY A

9 MATHS B

10 IT A

Professional Experience Details

1.Experience Details:

Sl No. Name of Institution/Company Designation Start Date End Date Duration Domain/Area

Certificate Details

Sl No. Name of Certificate Cert.No. Issue Date Authority

1 SSLC/THSLC or equivalent Certificate L3201827 28/04/2011 Dept. of General Education, Kerala

2 Community Certificate from Village Officer. 1890/14 07/06/2014 Village Officer, Ozhur

3 Income Certificate from Village Officer. 6458227 06/06/2014 Village Officer, Ozhur

Declaration1. I hereby declare that, I have read the various clauses in the Prospectus for Admission to Diploma Programmes (Evening) in

Polytechnic Colleges 2014 - 2015 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 Signature of the Applicant

Place:

Date:

Application No.: 124854Page : 3 of 3

Receipt

Received from VISHNUDAS O, S/D/W/o Sri. RAGHAVAN O,

application for Polytechnic Diploma (Evening) Admission 2014-15 (Application No. 124854) on ........................

at .......................................... Polytechnic College,......................................................... an amount of Rs. 200/-

is received as the application fee. The Application is registered with Registration No................

Polytechnic College Diploma (Evening) Admission Website: www.polyadmission.in

Seal of Receiving Polytechnic College Principal

Receipt

Received from VISHNUDAS O, S/D/W/o Sri. RAGHAVAN O,

application for Polytechnic Diploma (Evening) Admission 2014-15 (Application No. 124854) on ........................

at .......................................... Polytechnic College,......................................................... an amount of Rs. 200/-

is received as the application fee. The Application is registered with Registration No................

Polytechnic College Diploma (Evening) Admission Website: www.polyadmission.in

Seal of Receiving Polytechnic College Principal