Annai J.K.K. Sampoorani Ammal Polytechnic

ANNAI J.K.K. SAMPOORANI AMMAL POLYTECHNIC

Thookkanaickenpalayam – 638 506.

Gobi (Tk.), Erode (Dt.)

(Approved by AICTE, New Delhi.

F.No.: 418/GEN/E&T/98 Jan22, 1999)

Application Form For Admission To Diploma Course

SERIAL No. FOR OFFICE USE ONLY

Name of the Applicant

(To be filled up by the applicant)

1. a) Name of Candidate :

(in block letters)

b) Address for communication Name of the course

______

Sex Male Female

Pin Code______

2. Sex Code No. 1 2

______

3. Date of birth : (Christian Era) Day Month Year Age as on

(as found in SSLC or equivalent 1-7-1999

certificate)

Day, Month and year should be entered only as a two

Digit number, Example 5-6-1974 should be entered as

05 06 74

4. Community FC/BC/MBC & DNC/SC & ST BC MBC & DNC SC & ST

Name of the Community

4. a) Particulars of BC/MBC & DNC/SC & ST only:

i) Name of Caste:

ii) Sl. No. of the Certificate :

iii) Date of the Certificate:

iv) Office of issue of the Certificate :

v) Designation of Officer issuing :

Note :

The candidate should necessarily furnish the above particulars while submitting the application without fail. The candidate who does not furnish the above particulars at the time of submission of the application will be treated as Forward Community (i.e. O.C).,

The candidate should Produce the Original Community Certificate along with the Xerox/attested copy of the Community Certificate duly attested by officer of Grade A or B at the time of admission he/she is selected.

5. Examination Passed

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S.S.L.C.Years of passing (put only the)

(10 Yrs.) HSC Others last two digits of the year.

Code No. 1 2 3

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5. a) Certificate of marks in 10th Standard/Equivalent Examination : Xerox copy of 10th Standard Mark Transfer Certificate or 1st Page of SSLC Book should be enclosed with this application :

1. Name of School last Studied : (Address)State :

2. Register Number :

3. No. of attempts:

4. Month & Year of passing:

(Month)(Year)

6. Marks obtained in SSLC/Equivalent Examination Month & Year of Passing

i) Tamil or any other Language ………………. Marks out of ……………………………………………….

ii) English ………………. Marks out of ……………………………………………….

iii) Mathematics ………………. Marks out of ……………………………………………….

iv) Science………………. Marks out of ……………………………………………….

v) History & Geography………………. Marks out of ……………………………………………….

vi) Elective (if any)………………. Marks out of ……………………………………………….

………………………………………. Marks out of ……………………………………………….

vii) Total :………………. Marks out of ……………………………………………….

b) Details of marks secured in the prescribed Subjects

S.No. SubjectsMarks %

Basic Subjects – I (Maths/English)
Basic Subjects – II (Science)
Total (1 & 2)

7. Choice of Branch Order of Preference for courses

Civil Engineering a)

Mechanical Engineeringb)

Electrical & Electronics Engineering c)

Electronics & Communication Engineering d)

Chemical Technology e)

Textile Technology f)

Computer Technology g)

Petro Chemical Technology (Subject to AICTE approval)h)

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8. Are you an Indian by birth Yes No

9. Are you a Repatriate from Burma, Ceylon etc? Yes No

10. Your Place of Birth ______

Village/Town/City

11. Name of Native District ______

District

12. Civic Status of your Native Place

Mother Other Indian Other Foreign
Tongue Tamil Telugu Kanada Malayalam English Languages Languages
Code No. 1 2 3 4 5

14. Name of Parent / Guardian and Address ______

______

15. Occupation of Parent/Guardian

Occupation Agricul- Industry Business State Central Private Small Others
ture Govt Trade
Code No. 1 2 3 4 5 6 7 8

16. Name of the Occupation ______

17. Income of Parent/Guardian Annual Income :

Monthly Below Above
Income Rs. 500 Rs. 501-1000 Rs.1001-2000 Rs.2001-3000 Rs.3001-5000 Rs.5000
Code No. 1 2 3 4 5 6

18. Is your first father Ex-Serviceman Yes No Serviceman Yes No

19. Identify yourself against one of the categories :

Category GT Coy/ Ex.Serviceman Serviceman Burma Srilanka Widow Other
ASC (Ex.any) (Army) Repatriate Repatriate
Code 1 2 3 4 5 6 7

15. Extra Curricular activities

(Originals must be produced at the time of Admission)

Give details against each case

a)Sports

b)Games

c)N.C.C.

d)Social Service

e)Other extra curricular activities

(Give details)

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JOINT DECLARATION BY THE APPLICANT AND PARENT

I hereby solemnly and sincerely affirm that the statements made and the information furnished by me in the application as also in the enclosure there to submitted by me are true, should it however, be found that any information furnished therein is untrue in material particulars or on verification at a later stage. I am liable for criminal prosecution and I also agree to forego my seat in this institution/for removal of my name from rolls of the institution at whatever stage of study I may by at that time of detection of such wrong particulars I agree that the final admission in the above institution shall be subject to the approval of the Director of Technical Education Govt. of Tamilnadu Chennai.

Place :

Date :Signature of the Candidate

I am fully aware of the above declaration and I have understood of the same.

I agree for the above conditions.

Place :

Date :

Signature of the Parent / Guardian

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FOR OFFICE USE ONLY

Application found in order and the candidate is eligible for the course

Date :Manager :

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Admit to ______batch ______199

Date :Correspondent / Principal

Application Form For Admission To the

2ND YEAR (III SEMESTER) OF THE DIPLOMA COURSE, 1999)

Application / Filled in Applications should be sent to the concerned Principal of the institution to which Candidate seeks admission / Reg.No.
(To be assigned by Office)

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(To be filled up by the applicant)

1. a) Name of Candidate :Name of the Polytechnic / Institute

(in block letters) (Mention only one institution)

…………………………………………………………. ………………………………………………………….

b) Address for communication Name of the course : (in the order of preference)

…………………………………………………………. 1.5.

Pin Code______

For Non – Engineering Course apply in separate Application form

2. Sex :Male / Female

3. Date of birth : (Christian Era) Day Month Year Age as on

(as found in SSLC or equivalent 1-7-1999

certificate)

Day, Month and year should be entered only as a two

Digit number,Example 31-1-1973 should be entered as

0 3 0 1 7 3

4. Community FC/BC/MBC & DNC/SC & ST ST SC MBC & DC BC OC

In the box write the Serial No of your Community from the list of ST/SC/MBC & BC and Other Communities should enter 500)

4. b) Particulars of BC/MBC & DC/SC & ST only:

i) Name of Caste:

ii) Sl. No. of the Certificate :

iii) Date of the Certificate:

iv) Office of issue of the Certificate :

v) Designation of Officer issuing :

Note :

5. Certificate of Marks HSC Examination (Enclose Xerox copy of the HSC Marks Sheet in addition to furnishing the details below)

(i) Name of the School last studied : (Address) State …………………………………………

Sl.No. Class Year of passing Name of the school with address
(1)IX Std.
(2)X Std.
(3)HSC Equivalent

(ii) Register Number :…………………………………..

(iii) No. of Attempts:…………………………………..

(iv) Month & Year of passing : …………………………………..

…………………………….

HSC (Academic) Marks / (HSC Vocational) Marks
Parts I Tamil or Language : ………… out of ……………
Parts II English: ………… out of ……………
Part III Maths ………… out of ……………
Physics ………… out of ……………
Chemistry ………… out of ……………
Elective ………… out of ……………
Total ………… out of …………… / Parts I Tamil or Language : ………… out of ……………
Parts II English: ………… out of ……………
Part III Maths ………… out of ……………
Physics ………… out of ……………
Chemistry ………… out of ……………
Name of the Vocational Course …………………………
Theory : ………… out of ……………
Practical I : ………… out of ……………
Practical II : ………… out of ……………
Total ………… out of ……………

6. Nationality :…………… …………… …………… ……………

7. Place of Birth :………………………… ………………………… …………………………

VillageTown / City District State

8. Native District :…………… …………… …………… ……………

9. Mother Tongue

Mother Other Indian Other Foreign
Tongue Tamil Telugu Kanada Malayalam English Languages Languages
Code No. 1 2 3 4 5

10. Name of Parent / Guardian and Address ______

______

11. Occupation of Parent/Guardian Name of Occupation ……………………………………….

Occupation Agricul- Industry Business State Central Organisation Small
ture Govt Private Trade Trade
Code No. 1 2 3 4 5 6 7

12. Income of Parent / Guardian Annual Income …………………

Business Above Rs. 500 Rs. 501-1000 Rs.1001-2000 Rs.2001-3000 Rs.3001-5000 Above

Code No. 1 2 3 4 5 6
13. Extra Curricular activities
(Originals must be produced at the time of Admission)
Give details against each case
a)Sports
b)Games
c)N.C.C.
d)Social Service
Other extra curricular activities (Give details)

DECLARATION BY THE APPLICANT

I …………………………………………………….. (Name in full) Son/daughter of ………………………….. Solemnly declare that the information furnished and in the statements given in the application and the enclosures are true, correct and complete. I further declare that should it be otherwise, I will be liable to forfeit my seat and or removed from the rolls of the institution at whatever of study I may be, besides making me Liable for Criminal Prosecution.

Place :

Date :

Signature of Candidate

ANNEXURE I

JOINT DECLARATION BY THE PARENT / GUARDIAN AND THE CANDIDATE

I hereby solemnly and sincerely affirm

1. I, ……………………………………………… (Name in full)

Father/Mother of …………………………………. Hereby solemnly declare that I am fully aware of the declaration made by the applicant, my Son/Daughter and declare and bind myself on the same terms contained with above declaration. The statements and the information given are true, correct and complete. If it is found otherwise, the application is liable to forefeit the seat and or removed form the institution at whatever may be stage of study besides making me liable for Criminal Prosecution.

Note : Guardian can execute the above declaration only if the parents are not alive.

2. That my son/daughter/ward would confirm strictly to all rules and regulations in force now or which may be introduced in the institution hereafter and that I realize the breach of descipline and rules on my son’s / daughter’s / ward’s part would entail summarily forfeiture of his/her seat in the Institution.

3. That I am aware that if my son/daughter / ward does not put in a minimum of 80 percent attendance during the year in Theory Drawing and Practical classes separately, my son/daughter/ward will not be sent up for the Board Examination.

4. That I am aware that the curriculum for the various courses is not rigid and that, my/son/daughter/ ward will follow the syllabi for the various courses in force at the time of his/her admission and that any revision or modification made in the syllabi during the course of his/her study in the institution will be binding on him/her.

Place :

Date :

5 . That I am aware that if my son/daughter ward does not get minimum of 50 per cent of marks in the day to day valuation of his/her work and progress he/she will be not be sent up for the Board Examination.

6. That in case of my son’s/daughter’s/ ward’s progress in studies in uniformly door in the Institution his/her studies are liable to be terminated by the issue of Transfer Certificate.

7. That in Case my son/daughter/ward become a scholarship holder or comes to enjoy educational concessions like half-fee, or full-fee, etc., and does not show special progress, the scholarships or educational concessions are liable to be cancelled and that if my son’s / daughter’s / ward’s conduct and character are not good these will be cancelled.

8. That my son/daughter/ward is aware that breach of discipline and rules or bad conduct in the N.C.C. or extra – curricular activities will also entail summarily forfeiture of seat in the Institution in addition no such other proceedings that may be taken against him/her.

9. That I am aware that if my son/daughter/ward is admitted into the hostel/he/she will strictly abide by the rules and regulations in force in the hostel and that nay breach of discipline or rules or any unruly conduct or undesirable activities will be summarily deal with my forfeiture of seat both in the hostel and in the institution in addition to such other proceedings that may be taken against him/her.

Signature of the Candidate :

Signature of the Parent / Guardian