1115201

GENERALGovernment of Kerala

OFFICE OF THE COMMISSIONER FOR ENTRANCE EXAMINATIONSHousing Board Buildings, Santhi Nagar, Thiruvananthapuram - 695 001.

APPLICATION FOR ADMISSION TO PROFESSIONAL DEGREE COURSES, KERALA 2013

Application No. 11152011 Name of Applicant SHARANYA V

2 Course(s) opted Engineering,Medical,MBBS & BDS (NEET-UG 2013) 2(a) NEET UG Reg.No: 1089648

3 Centre of Examination KASARAGODE

4 Gender Female

5 Date of Birth 21/01/1995

6 Age as on 31/12/2013 18

7 Nativity Keralite

8 Citizenship Indian

9 Income NA

10 Special Reservation(s) NO

11 Permanent Address SHARANAM MANIYIL,CHATHANKAI,CHANDRAGIRI P O,671317

12 Communication Address SHARANAM MANIYIL,CHATHANKAI,CHANDRAGIRI P O,671317

13 Mobile Number 9747371496 Phone Number 04994236194 Email ID [email protected]

14 Village -- Taluk -- District --

15 Qualifying Examination QH,NA

16 Board KERALA BOARD OF PUBLIC EXAMINATIONS

17 Subjects Studied PHY,CHE,MATHS,BIO

18 Studied Sanskrit NO

19 Category Claim & Subcaste NA,NA

20 Claim Inter-caste NO

21 Person with Disability NO

DECLARATION

I hereby declare that I have read the various clauses in the Prospectus for Admission to Professional Degree Courses 2013 carefully and I agree to abide by them.

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 examination, action can be taken against me by the Commissioner for Entrance Examinations.

Signature of Parent/Guardian :

Place:

Date:

Signature of Candidate :

Place:

Date:

22. Candidate’s Identification:

Affix a recent passport

size photograph in this

box. Photo should be

identical to the uploaded

one to online application.

Attesting officer should

sign over the photograph

ATTESTATION BY THE PRINCIPAL/HEAD OF INSTITUTION WHERE THE CANDIDATE HAS STUDIED / IS STUDYING OR BY A GAZETTED OFFICER

I certify that the Photo is that of (Write name of Applicant).........................................................................

Name & Address of Attesting Officer :

(Office Seal)

23. Payment Details :

Pay Mode Security Card Card Sl. No. 5178650 Amount 700

CERTIFICATE CHECK LIST(Put in the appropriate squares if you enclose the following documents)

Nativity Certificate Course Certificate NEET UG 2013 Confirmation Page

OFFICE USE ONLY

GroupNativity

Comm. Res

Special Res.

PWD

Others

Remarks:

IT Services: NIC Kerala 1 IP Address:'.117.213.29.238 Final Submission Done on:16-01-2013 16:28:34 Printed on:20-01-2013 18:07:00

Page 1 of 3

Candidate Name : (1115201)

CERTIFICATE TO PROVE NATIVITY FOR KERALITES

Certified that, Shri/Smt /Kum ............................................................................................................................................... is an Applicant for the

Engineering/Medical/Agriculture Entrance Examination(s) 2013 and he/she | his/her father/mother Shri/Smt ....................................................

House...............................................................Village.......................................................... District ..........................................................,

...................................................................................................................................... was born in Kerala.

Signature of Village Officer/Tahsildar/Any Competent Authority :....................................

Name and Designation :.....................................

Place :

Date : (Office Seal)

OR*

In the absence of above certificate, candidate should submit self-attested photocopy of any one of the following certificates:

(i) True copy of the relevant page of the SSLC of the candidate showing the candidate's place of the birth in Kerala

(ii) True copy of the relevant page of the SSLC of the candidate's father/mother showing the place of birth in Kerala with corroborative evidence

proving the relationship between the candidate and the parent (father/mother) whose certificate has been produced.

(iii) True copy of the relevant page of the passport showing place of birth in Kerala issued by Govt. of India, of the candidate or either of parents with

corroborative evidence proving the relationship between the candidate and the parent (father/mother) whose true copy of Passport has been produced.

(iv) True copy of birth certificate of candidate or his/her, father/mother showing the place of birth in Kerala with corroborative evidence proving

the relationship between the candidate and the parent(father/mother) whose certificate has been produced.

IT Services: NIC Kerala Date:20/01/2013

Page 2 of 3

Name :SHARANYA V (1115201)

Note:

(1) Candidate should furnish the 'Course Certificate' given below as proof of subjects studied.

(2) B.Sc holders should attach copy of relevant degree/mark list (all parts) in addition to the certificate of Higher Secondary or equivalent examination.

(3) Candidates already passed the qualifying examination and applying for medical Entrance Exam can attach the copy

of their mark lists to prove academic eligibilty, 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 marksheet/pass certificate to prove academic eligibility)

CERTIFIED that Shri/Smt /Kum.………………………………………….………………, an applicant for Engineering/Medical/

Agriculture Entrance Examination(s) 2013, who is the son/daughter of Shri./Smt.……..…………………………………………………

of ……..………………………………………………………………………………………………………………………………………………

……..……………………………………………………………………………………………………………………………………(address)

*(a) is/was a student of Standard XII/equivalent during the year……..………………………………………….with

subjects as * (i) PHYSICS (ii) CHEMISTRY (iii) MATHEMATICS (iv) BIOLOGY (v) ……..…………………………………………..

(vi)……..…………………………………………..……and second language as…..………………………………………………..……

*(b)is/was a student of Three Year Diploma in Engineering

The date of birth of candidate as per school record is………………………………………………………………………

Signature of the Head of the Institution:……………………………………………

Name :…………………………………………

Designation :…………………………………………

Name of Institution :…………………………………………

District :……………………...……...……...……

Place :

Date : (Office Seal)

* Strike out whichever is not applicable.

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1115201