Application No.

17303

APPLICATION FORM FOR ADMISSION TO

PART TIME B.E. / B.TECH. DEGREE COURSES 2015–2016
Common application form to seek admission to Government and Government Aided Engineering
Colleges under unified Single Window Admission System for Indian Nationals
Last date for receipt of Application Application Cost : Rs. 300.00
08-05-2015 — 5.00 P.M. ST / SC / SCA : Rs. 150.00
* Read 'Information and Instructions to Candidates' before filling the Application Form.
* Encircle the Code Numbers wherever specified for the entries applicable to you.
1. GROUP CODE: Group Name :

(Refer 5.0 Information and Instructions to the Candidates)

Space for affixing the Passport
size Colour Photograph
2. Special Reservation (Differently abled) : 3. Presently Employed :
Yes No Yes No

1 2 1 2

4. Name in Block Letters :

(Initials at the end)

5. Address for Communication :

PIN
Email ID:

Contact Telephone No: Mobile No:

STD Code Telephone Number

6. Sex : 7. Date of Birth : 8. Citizenship: 9.Nativity:

Male Female Transgender Day Month Year Indian Others TamilNadu Others

1 2 3 1 2 1 2

10. Community: 11. Caste Code:

MBC/
ST SC SCA BC BCM OC
DNC
(Enter the Code Number of your Caste given in
1 2 3 4 5 6 7 the List of Communities – Annexure - I )

Counselling Centre : Coimbatore Institute of Technology, Coimbatore 641 014

Choice of College and Branch : Candidate may choose at the time of counselling

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 12. Qualifying Diploma particulars :
Application No. 17303
(a)Diploma Examination Registration Number : (c) Diploma Branch Name :

(b) Branch Code of the Qualifying Diploma Course: (d) Month and Year of
(Refer 5.0 Information and Instructions to the Candidates)
Month Year
passing Diploma :

13. Marks obtained in the Qualifying Examination (Refer 8.2 Information and Instructions to Candidates) :

Semester Month & Year of Passing Maximum

Marks Obtained *
Marks *
1st Semester
2nd Semester
3rd Semester
4th Semester
5th Semester
6th Semester
7th Semester
8th Semester
Total
* Including Theory and Practical subjects.
Overall % of Marks in the qualifying examination :
(Total Marks obtained / Total maximum Marks x 100)
%
Note :
1. Diploma (Regular) Candidates : Fill up marks from 1st Semester to 6th Semester
2. Diploma (Lateral Entry) Candidates : Fill up marks from 3rd Semester to 6th Semester
3. Sandwich Diploma Candidates : Fill up marks from 1st Semeter to 7th Semester.
However marks for industrial training will not be considered for selection.
4. Part-time Diploma Candidates : Fill up marks from 1st Semester to 8th Semester

14. Whether applying under Teacher’s quota : Yes No

1 2
15. (a) Details of permanent employment including present employment:
(Details of experience to be furnished from the date of qualifying Diploma to 08-05-2015).
(Refer 8.3 Information and Instructions to Candidates)

Name of Department / Organisation Period of Service Duration of Service

/ Institution and Place From To Years Month Days

Total
Note : 1. Attach a separate sheet if the space provided above is not s ufficient.
2. Work experience without Registration No./ Certificate No. of the firm will not be considered (Refer 8.4).
3. If proof of experience is not furnished along with application form, weightage for experience will not be awarded.

15. (b) Total Service in Months (As on 08–05–2015) :

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 16. Place of Present Employment :

(a) District Code : (b) District : Application No. 17303

(c) Village
/Town:
(Refer 10.0 Information and Instructions to the Candidates)

17. Distance from the place of work to the College applied for : (To be Filled by Candidates who are employed)
Distance in Kms.
Choice College Code Name of College
(Bus / Train route)

II
III
(Refer 1.0 – Colleges and Courses of Study in Information and Instructions to the Candidates)

Station : Signature of the Applicant

Date : (Name in Block Letters)
Permanent Employment Certificate (from the present Employer) *

Thiru / Thirumathi / Selvi…………..................................................................................................................

is employed on permanent Full-time basis as.................................................................... in the Organisation/
Department of................................................................................................................ from.….................……..........
as on date and is being sponsored to do Part-time B.E. course and in normal course shall continue to hold such
employment at the place of study throughout the period of his / her Part-time course. This Organisation / Department
has no objection to permit the candidate to do Part-time B.E./ B.Tech. Degree Course. At present the Candidate is working
at......................................................................................................................................and the distance from the place of
working to the College is correct as mentioned in Item No. 17.

Station : Signature:

Date : Office Seal Designation :

* This Certificate must be filled by the present employer. If this is not filled by the present employer, he / she will be treated
as unemployed.

DECLARATION BY THE APPLICANT AND THE PARENT/GUARDIAN

I,……………………………………………………………………………………(Name in full and in Block Letters)

Son/Daughter/Ward of…………………………………………………hereby solemnly declare that the information
furnished and the statements given in the application, and the enclosures are true, correct and complete. I further
declare that should it be found otherwise, I will be liable to forfeit my seat and / or be removed from the rolls of the
institution at whatever stage of study, I may be, besides making me liable for Criminal Prosecution.
Place :

Date : Signature of the Candidate

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 CHECK LIST FOR CANDIDATES
Mark a tick (√) in the appropriate box for each entry Application No. 17303
Sl.No Required Documents Yes No Sl.No Required Documents Yes No

Self Attested photograph 7 Self Attested copy of the

1 affixed on the Application. Permanent Community
Cer tificate card (if
applicable) enclosed.
2 Self Attested copy of the 8 Self Attested copy of
S.S.L.C. m a r k s h e et or Nativity C e r t i f i c a t e
its equivalent certificate ( i f a p p l i c a b l e )
enclosed. enclosed

3 Self Attested copy of all 9 Group Code and Group

semesters Diploma mark Name mentioned on the
sheets enclosed envelope

4 Self Attested copy of Diploma 10 Mailing Address and

Certificate enclosed. affixed Postage Stamps to
the required value in the
Acknowledgement Card
and also in a Counselling
5 Self Attested copy of the Call letter cover and
Transfer Certificate enclosed. attached them with the
Application.
6 S e l f A t t e s t ed copy / copies
o f Ce r t i f ic ates of previous /
p r e s ent Wor k Exper ience
enclosed.

For OFFICE USE ONLY

1. Application Complete : Yes No

1 2

* If ‘No’ tick the relevant item in the list of defects given below.
 Not Satisfying Tamil Nadu Nativity.
 Not Passed the prescribed qualifying examination.
 No Proper Community Certificate.
 Not Completed 2 years.
 Not Satisfying the Distance Rule.
 Not Employed
 Not having 2 years minimum experience

The Candidate is eligible / not Eligible Eligible Not Eligible

(if not eligible, Specify the reason)

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

1. Scrutinizing Staff Name……………………………………………………Signature………………………..……………..

2. Scrutinizing Staff Name……………………………………………………Signature………………………..……………..

4

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