Further communication regarding admission will be communicate to your registered email id only.

UG APPLICATION FORM 2023 - 2024

Eve Unaided Course Applicati Applied

Shift Shift II
EU22 EU22-48959 B.C.A
Code on No. Course

PERSONAL INFORMATION

Student Name : HEAM KUMAR D Date of Birth : 25/05/2004

Gender : Male Religion : Hindu

Community : SC Caste : Adi Dravida

Board of studies : State Board Nationality : Indian

Blood Group : B +ve Mode Of Transport : Public-Transport

Marital Status : Single Mother Tongue : Tamil

Student Mobile Number : 8056105616 Sports : Yes

Active participation
Sports Name/Level : / :
in any club

Student Email Id : heamkumar3925@gmail.comStudent Aadhar Card No : 574146779831

EMIS : Student Whatsapp No : 8056105616

Hostel Accommodation Required : No

Select the second language you prefered to choose in College : Tamil

Have you applied for any other course in our college : Yes

List of courses - 1. EU23-34199 , 2. EU22-48959 ,

Proficiency in other fields(Arts,Music,Dance,etc.,) : No

Did you lost your parents in Covid-19? : No

Are you from Tamil Nadu Origin Currently Living in Andaman and Nicobar
: No
Islands

Are you Studied +2 from another State

: No
(If So Produce eligibility certificate regarding community & course)

Government scholarship Received at school level : No

Are you from Other Country : No

Do you belong to linguistic minority : :

Whether your father/mother is a Non Resident India : No

Whether your Father or Mother working/worked in Defence Sector : No

Differently Abled (PWD) : No

CONTACT DETAILS
Temporary Address Permanent Address
NO.26/29, BAJANAI KOVIL STREET, MELMANAGAR, NO.26/29, BAJANAI KOVIL STREET, MELMANAGAR,
POONAMALLEE, TIRUVALLUR-600056 POONAMALLEE, TIRUVALLUR-600056

PARENT INFORMATION

Parent Name / Father is

Mobile Annual
Guardian Relation Occupation Education Email-ID Ex-Service
Number Income
Name Men(Y/N)

E PARTHIBAN UNCLE Supervisor DIP ( EEE ) 9884775616 2,40,000 No

No

6th,7th,8th,9th EDUCATIONAL DETAILS

Govt/Aided/Private/Matri
Class Institution Name Medium Board Stream
c

Ebenezer Jaganath Marcus Mat Hr Sec

VI English Private-Matric State Board Regular
School

Ebenezer Jaganath Marcus Mat Hr Sec

VII English Private-Matric State Board Regular
School

Ebenezer Jaganath Marcus Mat Hr Sec

VIII English Private-Matric State Board Regular
School

Ebenezer Jaganath Marcus Mat Hr Sec

IX English Private-Matric State Board Regular
School

10th,11th,12th EDUCATIONAL DETAILS

Month
Register Govt/Aided/Private/ and
Class Institution Name Medium Board Stream
Number Matric Passed
Year

Ebenezer Jaganath
X 2869126 English Private-Matric State Board Regular 2021
Marcus Mat Hr Sec School

Ebenezer Jaganath
XI 2795680 English Private-Matric State Board Regular 2022
Marcus Mat Hr Sec School

Ebenezer Jaganath
XII 7792023 English Private-Matric State Board Regular 2023
Marcus Mat Hr Sec School

X SUBJECT DETAILS

Subject Marks Total Marks No.of Attempts

English 100

Language 100

Maths 100

Science 100

Social 100
 X Subtotal(without language & English) : 0 X Subtotal Percentage(%) : 0.00 X Total(with language & English) : 0 X
Percentage(%): 0.00

XI & XII SUBJECT DETAILS

XI Total XI No.of XII XII Total XII No.of

Subject XI Marks
Marks Attempts Marks Marks Attempts

English 76 100 NIL 72 100 NIL

Language 60 100 NIL 55 100 NIL

Physics 50 100 NIL 75 100 NIL

Chemistry 46 100 NIL 90 100 NIL

Computer Science 84 100 NIL 85 100 NIL

Mathematics 40 100 NIL 52 100 NIL

XI Subtotal(without language & English) : 220 XI Subtotal Percentage(%) : 55.00 XI Total(with language & English)
: 356 XI Percentage(%): 59.33

XII Subtotal(without language & English) : 302 XII Subtotal Percentage(%) : 75.50 XII Total(with language & English)
: 429 XII Percentage(%): 71.50

I declare that all the particulars furnished above are true and correct (In case the furnished information is found to be
incorrect later, the application/admission will be rejected). I hereby agree that I will abide by the rules and regulations of the
college that are in force from time to time. I will follow the COVID-19 Protocal.

Place Signature of the Signature of the Applicant

Father/Mother/Guardian