GENERAL

Government of Kerala

OFFICE OF THE COMMISSIONER FOR ENTRANCE EXAMINATIONS

Housing Board Buildings, Santhi Nagar, Thiruvananthapuram - 695 001.

APPLICATION FOR ADMISSION TO PROFESSIONAL DEGREE COURSES, KERALA 2014

Application No.
1107726
1 Name of Applicant NANDAKISHOR A J

2 Centre of Examination MALAPPURAM

3 Course(s) opted Engineering 15 Qualifying Examination QH,NA

4 Gender Male 16 Board of Examination HS

5 Date of Birth 12/05/1997 17 Subjects Studied PHY,CHE,MATHS,CSC

6 Age as on 31/12/2014 17 18 Studied Sanskrit NO

7 Nativity Keralite 19 Category Claim & Subcaste NA,NA

8 Citizenship Indian 20 Claim Inter-caste NO

9 Income 700000 21 Person with Disability NO

10 Special Reservation(s) NO

11 Permanent Address KIZHATTUKUNNATH HOUSE,PARAPPUR IRINGALLUR,VENGARA P O,676304

12 Communication Address KIZHATTUKUNNATH HOUSE,PARAPPUR IRINGALLUR,VENGARA P O,676304

13 Mobile Number 9495531058 Phone Number 04942456200 Email ID nandakishoraj@gmail.com

14 Village Parappur Taluk Tirurangadi District Malappuram

DECLARATION
I hereby declare that I have read the various clauses in the Prospectus for Admission to Professional Degree Courses 2014 carefully and I agree to abide by them.
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 examination, action can be taken against me by the Commissioner for Entrance Examinations.

Signature of Parent/Guardian : Signature of Candidate :

Place: Place:
Date: Date:

22. Candidate’s Identification:

ATTESTATION BY THE PRINCIPAL/HEAD OF INSTITUTION

WHERE THE CANDIDATE HAS STUDIED / IS STUDYING OR BY A GAZETTED OFFICER

I certify that the Photo is that of (Write name of Applicant)...................................................... Affix a recent passport
attested by me is same as the photograph already printed in the application size photograph in this
box. Photo should be
identical to the uploaded
Name & Address of Attesting Officer :
one to online application.
Attesting officer should
sign over the photograph

(Office Seal)

23. Payment Details :

Pay Mode Security Card Card Sl. No. 4193138 Amount 800

CERTIFICATE CHECK LIST(Put in the appropriate squares if you enclose the following documents)

Nativity Certificate Course Certificate Income Certificate

OFFICE USE ONLY

Nativity Group Remarks:

Comm. Res PWD

Special Res. Others

IT Services: NIC Kerala IP Address:'.117.236.248.239 Final Submission Done on:11-01-2014 19:19:39 Printed on:15-01-2014 20:14:09

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Candidate Name :NANDAKISHOR A J (1107726)

CERTIFICATE TO PROVE NATIVITY FOR KERALITES

Certified that, Shri/Smt /Kum ............................................................................................................................................... is an Applicant for the

Admission to the Professional Degree Courses Kerala 2014 and he/she his/her father/mother Shri/Smt ....................................................
House...............................................................Village.......................................................... District ..........................................................,
...................................................................................................................................... was born in Kerala.

Signature of Village Officer/Tahsildar/Any Competent Authority :....................................

Name and Designation :.....................................
Place :
Date : (Office Seal)

OR*

In the absence of above certificate, candidate should submit self-attested photocopy of any one of the following certificates:
(i) True copy of the relevant page of the SSLC of the candidate showing the candidate's place of the birth in Kerala
(ii) True copy of the relevant page of the SSLC of the candidate's father/mother showing the place of birth in Kerala with corroborative evidence
proving the relationship between the candidate and the parent (father/mother) whose certificate has been produced.
(iii) True copy of the relevant page of the passport showing place of birth in Kerala issued by Govt. of India, of the candidate or either of parents with
corroborative evidence proving the relationship between the candidate and the parent (father/mother) whose true copy of Passport has been produced.
(iv) True copy of birth certificate of candidate or his/her, father/mother showing the place of birth in Kerala with corroborative evidence proving
the relationship between the candidate and the parent(father/mother) whose certificate has been produced.
(v) Original certificate issued by the competent authority showing that the parent of the candidate is an AIS officer allotted to Kerala cadre with corroborative evidence.

IT Services: NIC Kerala Date:15/01/2014

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Name :NANDAKISHOR A J (1107726)

Note:
(1) Candidate should furnish the 'Course Certificate' given below as proof of subjects studied.

(2) B.Sc holders should attach copy of relevant degree/mark list (all parts) in addition to the certificate of Higher Secondary or equivalent examination.

(3) Candidates already passed the qualifying examination should attach the copy of their mark lists to prove academic eligibilty, instead of course certificate.

COURSE CERTIFICATE
(To be issued by the Head of School/Institution where the applicant has completed or is
completing his/her studies in Standard XII or equivalent/Diploma in Engineering)
(Candidates who have passed the Plus Two/equivalent examination can attach
the self-attested copy of the marksheet/pass certificate to prove academic eligibility)

Certified that Shri/Smt /Kum.………………………………………….………………, an applicant for the Professional Degree

Courses Kerala 2014,who is the son/daughter of Shri./Smt.……..…………………………………………………
of ……..………………………………………………………………………………………………………………………………………………
……..……………………………………………………………………………………………………………………………………(address)

*(a) is/was a student of Standard XII/equivalent during the year……..………………………………………….with

subjects as * (i) PHYSICS (ii) CHEMISTRY (iii) MATHEMATICS (iv) BIOLOGY (v) ……..…………………………………………..
(vi)……..…………………………………………..……and second language as…..………………………………………………..……

*(b)is/was a student of Three Year Diploma in Engineering

The date of birth of candidate as per school record is………………………………………………………………………

Signature of the Head of the Institution:……………………………………………

Name :…………………………………………

Designation :…………………………………………

Name of Institution :…………………………………………

District :……………………...……...……...……

Place :
Date : (Office Seal)

* Strike out whichever is not applicable.

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Name: NANDAKISHOR A J (1107726)

Income Certificate*

No. ……………………………………… Village Office :……………………………………………………

Date :…………………………………………

Shri/Smt. ……………………………………………………, residing at …………………………………………………………… house,

…………………………………… village …………………………………… taluk, ………………………………… district had submitted

an application** on ……………………………………………… date to issue an Income Certificate for the purpose of Admission to

Professional Degree Courses 2014. He/She had declared that his/her annual income is Rs. ……………………………………………

On my enquiry, I certify that his/her annual family income is as per given below. The total members in the family are ………………

out of which ……………………… are employed,…………………… are studying and ……………………………… are unemployed.

Sources Income Salary/Pension Business Wages Income Rents Others Total

of from land (Other than from from
Income Family pension)*** labour persons abroad
Members
Father
Mother
Children

Total amount in figures: ……………………………………………………………………………………………………………………………

Total amount in words: ……………………………………………………………………………………………………………………………

In case, having more than three children,

amount to be deducted for excess children: ……………………………………………………………....……………………………………

Balance amount in figures: ……………………………………………………………………………………………………..…………………

Balance amount in words: …………………………………………………………………………………………………………………………

Signature:

Office Seal Name & Designation:

______________________________________________________

* Annual Income of the previous financial year to the date of application should be considered.

** The person to which Income Certificate is sought must be specified.

*** In the case of permanent employees, existing DA should be calculated with the basic pay for determining the annual family income.

IT Services: NIC Kerala Date:15/01/2014

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