ity
Institute Name Navalurkuttapatty, Srirangam(TK), Tiruchirapy
Constituent A
College,
alli-620027,
STUDENT DETAILS PROFORMA (For University Ex:
m Purpose)
Name of the Applicant
English (Ex: KAVITHA
ISELVAN K)
Photo
Name of the Applicant
Hamil (Ex: &ONST
Qesveustt &)
Course
Roll Number
Board in School
Medium of School
|Andhaar No
hallenged (Yes!
Visually Challenged
(Ves! No)
Mother Tongue
M
1 Status
ther / Guardian Name
Bioms ! .
uTgyemeusot Quy
Mother Name
Father / Guardian
Occupation
Rel
igion
Community mente
lnxcascarsce)
Sub Caste
Gender
of my knowledge and belief.
Hand Writing
Address
Distriet City/Pown/Village
Pin Code Mobile N
Declaration: I hereby declare that all statements made in this application are true, complete and correet to the best
Student Signature
Class Incharge H.O.D