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Application No: 100450

Government of Kerala DEPARTMENT OF TECHNICAL EDUCATION

APPLICATION FOR ADMISSION To M.Tech / M.Planning DEGREE COURSE 2011 - 12

1. Name in CAPITAL Letters, beginning from the left; initials at the end of the name.(Please insert one letter in a box) S H I J I L M P
2. Postal Address MEETHALEPURAYIL (H) ALAKODE (P.O), ALAKODE KANNUR (DIST) KERALA Pin Code 670571 Affix recent passport size photo 3 (a) Contact Telephone Number STD Code 0 4 6 0 2 2 5 Land Phone 5 0 2 5 4. Date of birth in Christian Era Day 1 3 Month 0 1 1 9 Year 8 7 shijilmp@gmail.com Caste Viswakarma Reservation Category GEN Annual Income 48000

Mobile No. 9 9 9 5 3 7 1 8 4 4 5 Sex Male 6 Is Keralite YES

E mail address,if any. Religion hindu

Details of GATE Examination passed Year 2011 Month 3 Reg.No. EC7106269 Score 222.00

Details of Qualifying Examination Degree Branch University Name of the College Is the College approved by AICTE Month and Year of Passing Semesters completed? Total Marks in all Semesters up to and including S7 Maximum Marks in all Semesters up to and including S7 8 4879 7150 B.Tech Electronics and Communication Engineering KANNUR UNIVERSITY Govt. College of Engineering, Kannur Yes Year: 2010 Month: 4

8 Choice of specialisation in the order of preference Choice 1 2 3 4 College TVE TVE TVE TCR Specialisation Applied Electronics and Instrumentation Microwave and television Engineering Signal Processing Communication Engineering and Signal GATE GATE GATE Category(Specify GATE/Non GATE/Sponsered) GATE

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RIT

Industrial Engineering and Management

GATE

Details of Application Fee DD No 048008 Date 03/06/2011 Name of Bank State Bank of India DECLARATION (To be filled by the candidate) Amount 250

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.

List of Enclosures: