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Application No: 13066

Government of Kerala DEPARTMENT OF TECHNICAL EDUCATION

APPLICATION FOR ADMISSION To M.Tech / M.Planning DEGREE COURSE 2012 - 13

1. Name in CAPITAL Letters, beginning from the left; initials at the end of the name.(Please insert one letter in a box) J I T H I N S A C H I D A N A N D A N
2. Postal Address PALLITHADATHIL SANYASI ODA P.O IDUKKI DIST Pin Code 685552 Affix recent passport size photo 3 (a) Contact Telephone Number STD Code 0 4 8 6 8 2 2 Land Phone 1 6 0 2 4. Date of birth in Christian Era Day 0 3 Month 0 9 1 9 Year 8 9 jithin.sdn@gmail.com Caste Sambava Reservation Category SC Annual Income 150000

Mobile No. 9 4 9 6 3 4 0 3 8 2 5 Sex Male 6 Is Keralite Yes

E mail address,if any. Religion HINDU

Details of GATE Examination passed Year 2012 Reg.No. 7180395 Score 314.00 Mark 20

Details of Qualifying Examination Degree Branch University Name of the College Is the College approved by AICTE Year of Passing Semesters Sem 1 & 2 Sem 3 Sem 4 Sem 5 Sem 6 Marks Scored 995 671 718 666 691 3741 5950 100 No B.Tech Electronics and Communication Engineering COCHIN UNIVERSITY OF SCIENCE AND TECHNOLOGY College of Engineering Munnar Yes 2011 Semwise Mark Details Total Marks 1550 1100 1100 1100 1100

Total Marks in all Semesters up to and including sem 6 Maximum Marks in all Semesters up to and including sem 6 8 9 Fee Amount Whether Physically Challenged

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10 Applying for Institution in 11 Sponsored Candidate 12 Choice of specialisation in the order of preference Choice 1 2 3 4 5 6 7 8 College RIT TVE TVE TVE TCR RIT NSS WYD

Anexure A No

Specialisation Advanced Communication and Information system Microwave and television Engineering Applied Electronics and Instrumentation Signal Processing Communication Engineering And Signal Processing Industrial Engineering and Management Communication Engineering Communication Engineering And Signal Processing DECLARATION (To be filled by the candidate)

Category GATE GATE GATE GATE GATE GATE GATE GATE

I, . hereby solemnly and sincerely affirm that the statements made and information furnished in this application and also in the enclosures thereof submitted by me are true to the best of my knowledge and belief.I hereby agree to abide by the rules and regulations of the college,if admitted. Place: Date: Signature of the Candidate

Note: 1.Late applications, those which do not contain the necessary documents specified in clause of the prospectus and in which any certificate is found defective, will be rejected. 2.Those who have not secured qualification from the universities in Kerala state ,shall produce equivalency certificate at the time of admission/counseling.

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List of Enclosures: Self attested true copy of Engineering Degree certificate and Mark lists. Self attested true copy of GATE Score card (for Candidates with valid GATE Score) Self attested true copy of Community and Income certificate issued by the village officer for candidates who claim eligibility under SEBC quota. Self attested true copy of Community certificate issued by the Tahsildar for candidates who claim eligibility for reservation under SC/ST quota. Self attested true copy of professional experience certificate from the Head of the organizations where the candidate is working in case of those who passed AMIE/AMIETE. Self attested true copy of Nativity Certificate. Counterfoil of Chalan after remittance of application fee in any branch of SBT. Additional Certifiates: Self attested true copy of Sponsorship Certiciate. Self attested true copy of Physical Disability Certificate.

Page 4 of 4 Instructions to Bank:Please note to enter the Application No and Student name in the mandatory fields while posting the amount in the Current Account. STATE BANK OF TRAVANCORE Branch: Challan No: Bank Copy Fee Payment Voucher

To be Filled by Student Date:............................ Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481. Application No Name of Student: Amount:

13066
JITHIN SACHIDANANDAN 100 Commission:

Name of Degree:

MTECH

20

Total:

120

Name and Address of Student: PALLITHADATHIL SANYASI ODA P.O IDUKKI DIST 685552 Mobile Number: 9496340382 Amount in words: One Hundred and Twenty Only Signature:................................. Cashier:

Bank Seal

Passing Officer:

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Branch: Challan No:

Student Copy

To be Filled by Student

Date:............................ Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481. Application No Name of Student: Amount:

13066
JITHIN SACHIDANANDAN Commission:

Name of Degree:

MTECH Total:

100 Name and Address of Student: PALLITHADATHIL SANYASI ODA P.O IDUKKI DIST 685552 Mobile Number: 9496340382

20

120

Bank Seal

Signature:................................. Cashier:

Passing Officer:

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Branch: Challan No: Orginal Copy To be submitted along with the Application _____________________________________ To be Filled by Student Date:............................

Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481. Application No Name of Student: Amount:

13066
JITHIN SACHIDANANDAN Commission:

Name of Degree:

MTECH Total:

100 Name and Address of Student:

PALLITHADATHIL SANYASI ODA P.O IDUKKI DIST 685552

20

120

Bank Seal

Mobile Number: 9496340382 Signature:................................. Cashier: Passing Officer: