APPLICATION FORM FOR DIRECT ADMISSION IN ENGINEERING COURSES OF POLYTECHNICS IN RAJASTHAN ADMISSION 2011-2012

Registration No. Form No.

Admission Merit No. ___________

1. NAME OF CANDIDATE (IN ENGLISH) : _________________________________________ _________________________________________ (IN HINDI) : __________________________________________ __________________________________________

Affix Passport size Photograph of the candidate duly signed by candidate and attested by the principal or his nominee

2.

FATHERS / HUSBANDS NAME

: __________________________________________

3.

MOTHERS NAME

: __________________________________________

4.

POSTAL ADDRESS (Do not repeat name again)

:___________________________________________

___________________________________________

Dist. _________State_________Pin code___________

5.

SEX

MALE FEMALE

6.

DATE OF BIRTH

7.

CATEGORY OF RESERVATION

1 2 3 4

GENERAL SC ST OBC

5 6 7 8

SBC MP PH OTHERS

REGILION

: 1
2 3 4 5

HINDU MUSLIM SIKH CHRISTIAN OTHERS

9.

Whether you want admission under Tuition fee waiver scheme (TFWS) :

YES

NO

10. ACADEMIC RECORD:

SECONDARY / EQUIVALENT EXAM Sr. SECONDARY / EQUIVALENT EXAM Details of ITI Certificate Holder

Max. Marks Maths Science Aggregate of All Subjects Name of Board & Year of Passing Marks Improved?

Marks Obt.

Optional Subjects Maths Physics Chemistry Aggregate including compulsory subjects Name of Board & Year of Passing Marks Improved?

Max. Marks

Marks Obt.

Max. Marks Marks Obt. Name of Engg. Trade Duration Year of passing Name of Institute

Yes / No

Yes / No

Marks Improved?

Yes / No

It is certified that (i) All the entries in this form have been made by me and all are correct. I shall be responsible for any incorrect information provided by me. (ii) I have read all the information & rules given in the brochure. I shall abide by all the rules of the Polytechnic, Hostel and Board of Technical Education Rajasthan.

Signature of the Candidate

DECLARATION BY FATHER / GUARDIAN I ________________________________________ ( Fathers / Guardians Name) of the Candidate Sh. / Ms. ____________________________________ take all the responsibilities for his/ her conduct & maintainance of discipline of my Son / Daughter / Wife / Ward during the duration of his/her studies in the Polytechnic. The information given by him / her in the form are correct. Signature of Father / Guardian

FOR OFFICE USE Sr. No. 1 2 3 4 5 6 7 Eligibility Marks & Date of Birth Category Reservation Medical Certificate Branch Allotted College Allotted Allot Category Criteria Remark Signature

Fees Deposited Receipt No. DD No. & Bank / Cash Admitted / Not Admitted