Government of Kerala
Application No.
1113702
1 Name of Applicant SAFEENA NASRIN
8 Special Reservation NA
DECLARATION
I hereby declare that I have download and read various Clauses in the Prospectus for Admission to Professional Degree Courses 2017 carefully and I agree to
abide by them. I also declare that all the statements made in online 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, action can be taken against me by the Commissioner for Entrance Examinations.
I certify that the Photograph pasted on the application represents the true
identity of .....................................................................(write name of applicant)
I also certify that the photograph pasted on this application and the Affix the passport size
photo in this box. The
photograph printed on this application are same.
photo should be identical
to the photograph printed
on this application.
(Office Seal) Attesting officer should
sign over the photograph
KEAM-2017: IT Services: NIC Kerala 2 IP Address:'.202.83.57.10 Final Submission Done on:02-02-2017 20:12:36 Printed on:02-02-2017 20:15:27
Candidate Name :SAFEENA NASRIN (1113702)
(i) Self attested copy of Birth Certificate/SSLC/Relevant page of the Passport of candidate showing the candidate's
place of birth in Kerala.
(OR)
(ii) Self attested copy of Birth Certificate/SSLC/relevant page of the Passport of the candidate's father/mother showing
their place of birth in Kerala along with corroborative certificate to establish the relationship between the parent and
the candidate.
(OR)
(iii) Original certificate issued by the competent authority showing that the parent is an AIS officer allotted to
Kerala cadre with corroborative evidence proving the relationship between the candidate
and the parent.(Clause 6.1.(i))
(OR)
(In the absence of above certificates, obtain the following certificate from the Revenue officials to prove nativity)
CERTIFICATE OF BIRTH
is an Applicant for the Admission to the Professional Degree Courses Kerala 2017 and he/she was born in Kerala.
(OR)
Admission to the Professional Degree Courses Kerala 2017 and his/her father/mother Shri/Smt ................................................................................
Place :
Date :
(Office Seal) [Strike out whichever is not applicable]
KEAM-2017 : IT Services: NIC Kerala Date:02/02/2017
Name :SAFEENA NASRIN (1113702)
Note:
(1) Candidate's who appeared/are appearing for the qualifing examination should furnish the 'Course Certificate' given below as proof of subjects studied.
(2) B.Sc holders should attach self attested copies of mark lists of all parts of B.Sc Degree Examination in addition to the marklist of Higher Secondary
or equivalent examination.
(3) Candidates already passed the qualifying examination should attach the copy of their mark lists to prove academic eligibility, instead of course certificate.
COURSE CERTIFICATE
(To be issued by the Head of School/Institution where the applicant has completed or is
completing his/her studies in Standard XII or equivalent/Diploma in Engineering)
(Candidates who have passed the Plus Two/equivalent examination can attach
the self-attested copy of the mark sheet/pass certificate to prove academic eligibility)
(OR)
*(b)is/was a student of Three Year Diploma with Mathematics as one of the subjects
Name :
Designation :
Name of Institution :
District :.........
Place :
Date : (Office Seal)
* Strike out whichever is not applicable.
Name: SAFEENA NASRIN (1113702)
which is designated as a Socially and Educationally Backward Class (SEBC) / Other Eligible Communities (OEC)
does not belong to the category of Creamy Layer in the light of the guidelines dated ....................................
and the schedule prescribed thereunder to exclude the Creamy Layer among the designated
Socially and Educationally Backward Classes (SEBCs) / Other Eligible Communities (OEC) in the State of Kerala.
Designation:
Office Seal
KEAM - 2017
Note:- The above documents are listed based on the information provided by the candidate at the time of filled-up application.
If any of the required proforma of certificate not obtained while printing the application, it can be downloaded from the home of application portal.
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From To
SAFEENA NASRIN The Commissioner for Entrance Examinations
THIRUMANGALATH 5th Floor, Housing Board Buildings,
KUTTIKKATTOOR Santhi Nagar,
KUTTIKKATTOOR Thiruvananthapuram, Kerala.
Kozhikode, Kerala PIN: 695001
PIN: 673008