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 :