You are on page 1of 4

Page 1 of 4

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

7

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

Late applications. 2.shall produce equivalency certificate at the time of admission/counseling. Place: Date: Signature of the Candidate Note: 1.Page 2 of 4 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. .I hereby agree to abide by the rules and regulations of the college.if admitted. those which do not contain the necessary documents specified in clause of the prospectus and in which any certificate is found defective.Those who have not secured qualification from the universities in Kerala state . will be rejected. ………………………………………………………………………………………. 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.

Self attested true copy of Physical Disability Certificate. Self attested true copy of Nativity Certificate. . 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. Counterfoil of Chalan after remittance of application fee in any branch of SBT. 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. Additional Certifiates: Self attested true copy of Sponsorship Certiciate.Page 3 of 4 List of Enclosures: Self attested true copy of Engineering Degree certificate and Mark lists. Self attested true copy of Community certificate issued by the Tahsildar for candidates who claim eligibility for reservation under SC/ST quota.

.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.Trivandrum .Trivandrum .. Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No.Trivandrum ............... Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No......... Fort Branch.......481......code ... Cashier: Passing Officer: .....O IDUKKI DIST 685552 Mobile Number: 9496340382 Amount in words: One Hundred and Twenty Only Signature:...........code ..... 67179772330 with SBT.481...O IDUKKI DIST 685552 Mobile Number: 9496340382 20 120 Bank Seal Signature:.......................... Cashier: Bank Seal Passing Officer: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Branch: Challan No: Student Copy To be Filled by Student Date:.. 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..... Cashier: Passing Officer: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Branch: Challan No: Orginal Copy To be submitted along with the Application _____________________________________ To be Filled by Student Date:.............. STATE BANK OF TRAVANCORE Branch: Challan No: Bank Copy Fee Payment Voucher To be Filled by Student Date:............. Fort Branch.. 67179772330 with SBT................. Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No...O IDUKKI DIST 685552 20 120 Bank Seal Mobile Number: 9496340382 Signature:...........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.......... Fort Branch.............. 67179772330 with SBT.. 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...code .