Application to Polytechnic College Diploma (Evening) Admission 2014-15 Application No.: 124869 Page : 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, Tirur College where candidate seeks 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: VISAKH T K 2. Name of Father/Mother/ SHANMUGHAN T K 3. Relationship with Applicant: Father Guardian 4. Communication Address: Thondalam Kunnath, Thanalur P.O,Malappuram Dist PIN CODE: 676307 5. Mobile No.: 9946184683 6. E-mail: 7. Gender: Male 8. Date of Birth: 17/03/1995 9.Nationality: Indian 10. Native District: Malappuram 11.Annual Family Income: 30000 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: 2012 4.Exam Register No.: 247571 5.No. of Chances Taken: 1 Application No.: 124869 Page : 2 of 3 6.Mark List Sl. No. Subject Name Grade 1 LANG I B 2 LANG II B+ 3 ENGLISH C 4 HINDI C 5 SOCIAL C+ 6 PHYSICS C 7 CHEMISTRY D+ 8 BIOLOGY B 9 MATHS D+ 10 IT B+ 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 M442676 26/04/2012 Dept. of General Education, Kerala 2 Community Certificate from Village Officer. 6976009 04/07/2014 Village Officer, Thanalur 3 Income Certificate from Village Officer. 6973110 04/07/2014 Village Officer, Thanalur Declaration 1. 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.: 124869 Page : 3 of 3 Receipt Received from VISAKH T K, S/D/W/o Sri. SHANMUGHAN T K, application for Polytechnic Diploma (Evening) Admission 2014-15 (Application No. 124869) 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 VISAKH T K, S/D/W/o Sri. SHANMUGHAN T K, application for Polytechnic Diploma (Evening) Admission 2014-15 (Application No. 124869) 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