C.S.I. THOOTHUKUDI - NAZARETH DIOCESE
JAYARAJ ANNAPACKIAM
C.S.I. POLYTECHNIC COLLEGE
MARGOSCHIS NAGAR, NAZARETH - 628 617. Thoothukudi District
Approved by AICTE and Affiliated to DOTE
APPLICATION FOR ADMISSION TO DIPLOMACOURSE/LATERAL
ENTRY TO DIPLOMA COURSE 2015 - 2016
Internet Application No.
OFFICE USE ONLY
ADMIT
Admission Date :
SUBJECT
Principal's Signature
Branch Allotted :
PLEASE QUOTE APPLICATION NUMBER IN ALL COMMUNICATION
1.
Read all the Instructions before filling in the application in Candidate’s OWN HAND WRITING
2.
Tick Wherever applicable
3.
This
application
is
for
consideration
of
admission
under
the
Management
Quota
for
candidates belonging to Christian Community and for admission under ‘’Lapsed Seates’’ for candidates belonging
to any community.
4.
Xerox Copies of mark statements, certificates and other testimonials duly attested should be attached and the
originals should be produced at the time of interview
5.
Incomplete application forms will not be considered and will summarily be rejected
6.
Fill in your address the column below in Block Letters
Name & Address of applicant (For Communication)
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________
_____________________
Tel. No. (Code : _____________) ___________________
Pin
Cell No.: ____________________________
7.
Total Marks obtained in the qualifying Examination :
8.
Engineering Branch requested - Order of Choice
i)___________________________
ii) ___________________________ iii) _________________________
I. PERSONAL DATA
1. a) Applicant's name with initials (in Block Letters)
b) Expansion of all initials
2. Sex
Male
Female
3. a) Age (as on 1.7.200 ) years
b) Date of Birth
Date
c) Place of Birth
Village
Month
Year
Town
District :
d) Are you a citizen of India
Yes
City
State :
No
e) If not an Indian Citizen, State Nationality
4. a) Religion
b) Community Forward
Backward
Most Back Ward
Scheduled Caste
Scheduled Tribe
Denotifie
c) Caste / Sub - Caste
5. a) Mother Tongue
b) Languages Known
6. Name of Parent / Guardian*
7. Occupation of Parent / Guardian*
8. Annual Income of Parent
* When a parent is alive (father or mother) the question of Guardian does not arise
II. CURRICULAR AND EXTRA - CURRICULAR INFORMATION
i)
Qualifying Examination Passed
ii) Name and address of the Institution
iii) University / Board of Qualifying Examination
iv) Medium of Instruction
v) Number of attempts to pass the qualifying Examination
vi) Marks obtained in the qualifying examination
a) S.S.L.C. / Equivalent
Subject
Maths
Science
Month &Year Maximum Marks Marks Obtained
Percentage
b) H.S.C. Academic / Vocational Stream / Equivalent
Subject
Month & Year Maximum Marks Marks obtained Percentage
A. Maths /
Other Related
B. Physics /
Vocational
C. Chemistry
Practical II
vii) Total Marks obtained .................................. out of ......................... Percentage ............................
VIII) Extra Curricular Activities
Sports / Games
NCC / Scout
N.S.S
Anyother Prizes / Medals won (Specify)
CHECK LIST ENCLOSURE :
A. Before sending the application, the candidates should check whether the following documents are attached
1. Photocopy of certificate of qualifying examination (including all mark sheets)
2. Photocopy of other certificates
3. Photocopy of Birth Certificates
4. Photocopy of conduct and transfer certificate
5. Photocopy of community certificate
6. Copy of nativity certificate if the candidate claims Tamilnadu Nativity but has not passed the SSLC / HSC
B. At the time of Admission after the interview :
The following certificates must be submitted in Original :
For Tamil Nadu Candidates :
1. Community Certificate
2. Mark Sheets
3. Transfer Certificate
4. Conduct Certificate
For other State Candidates :
1. Community Certificate
2. Mark Sheets
3. Transfer Certificate
4. Conduct Certificate
5. Migration Certificate
III. JOINT DECLARATION BY THE APPLICANT & PARENT
I here by solemnly and sincerely affirm that, I have read and fully understood the rules and code of campus conduct of
the College and hostel found in the application and I promise that I shall follow the same. In case of default, I agree to
forego my seat in this college and hostel. Moreover, I hereby solemnly and sincerely affirm that the date of birth and all
the information furnished in the application and enclosures submitted by me are true. Should it, however, be found that
any information furnished there is untrue in material particulars on verification at a laterdate. I accept that I am liable for
criminal prosecution and also agree to forego my seat in this institution and removal of my name from the rolls of the
Institution at whatever state of study I may be at the time of detection of such wrong particulars.
I am fully aware of the above declaration and have understood the same. I agree to the above conditions
Place :
Sign. of the applicant
Date :
Name :
Sign. of the Parent / Guardian
Name
: