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GOVERNMENT OF KERALA

DEPARTMENT OF TECHNICAL EDUCATION


Application to Polytechnic College Diploma (Evening) Admission 2014-15
Application No.: 125181
Page : 1 of 3
Date of online entry: 05/07/2014
Fee to be remitted: Rs. 100/-
at Polytechnic College
Polytechnic College, Application Type and Programmes chosen for Admission
1. Name of the Polytechnic S.S.M. Polytechnic College, Tirur
College where candidate
seeks admission:
2. Application Type : General
3. Diploma Programmes which
candidate seeks admission:
1 Civil Engineering
Basic Details
1. Name of the Candidate: MUNEER VALIYAKATH
2. Name of Father/Mother/ HUSSAIN VALIYAKATH 3. Relationship with Applicant: Father
Guardian
4. Communication Address:
Mass villa, Ullanam P.O., Parappanangadi, Malappuram Dist
PIN CODE: 676303
5. Mobile No.: 7736668697 6. E-mail:
7. Gender: Male 8. Date of Birth: 20/03/1985
9.Nationality: Indian 10. Native District: Malappuram
11.Annual Family Income: 40000
Community Details
1.Are you eligible for No 2.Community Muslim
reservation under
inter-caste married
2.Whether OEC: No
Other Reservation Details
1.Have you passed ITI: No 2.ITI Trade:
3.Have you passed VHSE: No 4.VHSE Trade:
5.Have you passed KGCE: No 6.KGCE Trade:
Academic Details
1.Name of Examination: SSLC 2.No. of Subjects: 12
3.Year of Passing: 2001 4.Exam Register No.: 394155
5.No. of Chances Taken: 1
Application No.: 125181
Page : 2 of 3
6.Mark List
Sl. No. Subject Name Max. Marks Marks
1 FIRST LANG I 50 21
2 FIRST LANG II 50 29
3 ENGLISH I 50 15
4 ENGLISH II 50 12
5 HINDI 50 13
6 HISTORY 50 21
7 GEOGRAPHY 50 21
8 PHYSICS 50 22
9 CHEMISTRY 50 14
10 BIOLOGY 50 21
11 MATHS I 50 23
12 MATHS II 50 22
Professional Experience Details
1.Experience Details:
Sl No. Name of Institution/Company Designation Start Date End Date Duration Domain/Area
Certificate Details
Sl No. Name of Certificate Cert.No. Issue Date Authority
1 SSLC/THSLC or equivalent Certificate 129312 01/06/2001 Dept. of General Education, Kerala
2 Community Certificate from Village Officer. 6994618 05/07/2014 Village Officer, Neduva
3 Income Certificate from Village Officer. 6991537 05/07/2014 Village Officer, Neduva
Declaration
1. I hereby declare that, I have read the various clauses in the Prospectus for Admission to Diploma Programmes (Evening) in
Polytechnic Colleges 2014 - 2015 and the instructions carefully and I agree to abide by them.
2. I also declare that all the statements made in this application are true, complete and correct to the best of my knowledge
and belief and that in the event of any information being found false or incorrect or ineligibility being detected before or
after the admission, action can be taken against me.
Signature of the Parent/Guardian Signature of the Applicant
Place:
Date:
Application No.: 125181
Page : 3 of 3
Receipt
Received from MUNEER VALIYAKATH, S/D/W/o Sri. HUSSAIN VALIYAKATH,
application for Polytechnic Diploma (Evening) Admission 2014-15 (Application No. 125181) on ........................
at .......................................... Polytechnic College,......................................................... an amount of Rs. 100/-
is received as the application fee. The Application is registered with Registration No................
Polytechnic College Diploma (Evening) Admission Website: www.polyadmission.in
Seal of Receiving Polytechnic College Principal
Receipt
Received from MUNEER VALIYAKATH, S/D/W/o Sri. HUSSAIN VALIYAKATH,
application for Polytechnic Diploma (Evening) Admission 2014-15 (Application No. 125181) on ........................
at .......................................... Polytechnic College,......................................................... an amount of Rs. 100/-
is received as the application fee. The Application is registered with Registration No................
Polytechnic College Diploma (Evening) Admission Website: www.polyadmission.in
Seal of Receiving Polytechnic College Principal