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Application No: 17982

Government of Kerala DEPARTMENT OF TECHNICAL EDUCATION

APPLICATION FOR ADMISSION To M.Tech / M.Planning DEGREE COURSE 2013 - 14

1. Name in CAPITAL Letters, beginning from the left; initials at the end of the name.(Please insert one letter in a box) M O H A M M E D I R S H A D R
2. Postal Address IQSHAD MAHAL P.O VELUTHUR THRISSUR-680016 Pin Code 680016 Affix recent passport size photo 3 (a) Contact Telephone Number STD Code 0 4 8 7 2 3 1 Land Phone 0 7 4 4 4. Date of birth in Christian Era Day 2 5 Month 0 5 1 9 Year 9 0 mohd.shadu@gmail.com Caste MAPPILA Reservation Category SEBC Annual Income 435000

Mobile No. 9 0 3 7 4 0 2 0 0 7 5 Sex Male 6 Is Keralite Yes

E mail address,if any. Religion ISLAM

Details of GATE Examination passed Year 2013 Reg.No. CE16861072 Score 310.00 Mark 30.33

Details of Qualifying Examination Degree Branch University Name of the College Is the College approved by AICTE Year of Passing Semesters Sem 1 & 2 Sem 3 Sem 4 Sem 5 Sem 6 Marks Scored 6.3 5.6 6.6 6.2 6.0 6.12 10 500 No B.Tech Civil Engineering KERALA UNIVERSITY COLLEGE OF ENINEERING TRIVANDRUM Yes 2012 Semwise Mark Details Total Marks 10 10 10 10 10

Total Marks in all Semesters up to and including sem 6 Maximum Marks in all Semesters up to and including sem 6 8 9 Fee Amount Whether Physically Challenged

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10 Sponsored Candidate 11 Choice of specialisation in the order of preference Choice 1 2 3 4 5 6 7 8 9 10 11 12 13 15 College TVE TVE TVE TVE TCR TCR MAC RIT TKM TVE TVE KNR RIT TVE

No

Specialisation Traffic and Transportation Engineering Environment Engineering Hydraulics Engineering Geo Informatics Environment Engineering Water Resource and Hydro Informatics Structural Engineering and Construction Management Transportation Engineering Structural Engineering and Construction Management Geotechnical Engineering Structural Engineering Computer Aided Structural Engineering Industrial Engineering and Management Planning(Housing) DECLARATION (To be filled by the candidate)

Category GATE GATE GATE GATE GATE GATE GATE GATE GATE GATE GATE GATE GATE GATE

I, . hereby solemnly and sincerely affirm that the statements made and information furnished in this application and also in the enclosures thereof submitted by me are true to the best of my knowledge and belief.I hereby agree to abide by the rules and regulations of the college,if admitted. Place: Date: Signature of the Candidate

Note: 1.Late applications, those which do not contain the necessary documents specified in clause of the prospectus and in which any certificate is found defective, will be rejected. 2.Those who have not secured qualification from the universities in Kerala state ,shall produce equivalency certificate at the time of admission/counseling.

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List of Enclosures: Self attested true copy of Engineering Degree certificate and Mark lists. Self attested true copy of GATE Score card (for Candidates with valid GATE Score) Self attested true copy of Community and Income certificate issued by the village officer for candidates who claim eligibility under SEBC quota. Self attested true copy of Community certificate issued by the Tahsildar for candidates who claim eligibility for reservation under SC/ST quota. Self attested true copy of professional experience certificate from the Head of the organizations where the candidate is working in case of those who passed AMIE/AMIETE. Self attested true copy of Nativity Certificate. Counterfoil of Chalan after remittance of application fee in any branch of SBT. Additional Certifiates: Self attested true copy of Sponsorship Certiciate. Self attested true copy of Physical Disability Certificate.

Page 4 of 4 Instructions to Bank:Please note to enter the Application No and Student name in the mandatory fields while posting the amount in the Current Account. STATE BANK OF TRAVANCORE Branch: Challan No: Bank Copy Fee Payment Voucher

To be Filled by Student Date:............................ Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481. Application No Name of Student: Amount:

17982
MOHAMMED IRSHAD R 500 Commission:

Name of Degree:

MTECH

20

Total:

520

Name and Address of Student: IQSHAD MAHAL P.O VELUTHUR THRISSUR-680016 680016 Mobile Number: 9037402007 Amount in words: Five Hundred and Twenty Only Signature:................................. Cashier:

Bank Seal

Passing Officer:

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Branch: Challan No:

Student Copy

To be Filled by Student

Date:............................ Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481. Application No Name of Student: Amount:

17982
MOHAMMED IRSHAD R Commission:

Name of Degree:

MTECH Total:

500 Name and Address of Student: IQSHAD MAHAL P.O VELUTHUR THRISSUR-680016 680016 Mobile Number: 9037402007

20

520

Bank Seal

Signature:................................. Cashier:

Passing Officer:

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Branch: Challan No: Orginal Copy To be submitted along with the Application _____________________________________ To be Filled by Student Date:............................

Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481. Application No Name of Student: Amount:

17982
MOHAMMED IRSHAD R Commission:

Name of Degree:

MTECH Total:

500 Name and Address of Student:

IQSHAD MAHAL P.O VELUTHUR THRISSUR-680016 680016

20

520

Bank Seal

Mobile Number: 9037402007 Signature:................................. Cashier: Passing Officer: