NAME OF CANDIDATE(English):
PHONE NO. MOBILE NO.
DATE OF BIRTH
CATEGORY OF RESERVATION;
10- ACADEMIC RECORD:
Secondary / Equivalent Exam.
Sr. Sec. (With PCM)/ Equivalent Exam.
Max. Marks Marks obtained
Aggregate of all
If applied previously then:
It is certified that:
All entries in this form have been made by me and are all correct. I
shall be responsible for any incorrect information provided by me.
I have read all the information and rules given in the website. I shall
abide by all the rules of the polytechnic, hostel and Board of Technical
Signature of the Candidate
Declaration by the Father/Guardian:
I _____________________________( Fathers/Guardians name),
of candidate Sh./MS ____________ take all responsibilities of his/her conduct &
maintenance of discipline of my son/daughter/wife/ward during the duration of
his/her studies in the polytechnic.
The information given by him/her in the form are correct.
Signature of the Father/Guardian
For office use:
Category Eligibility Marks Medical Certificate Date of Birth
Signature of Checker