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Application No: 22882Government of Kerala
DEPARTMENT OF TECHNICAL EDUCATION
APPLICATION FOR ADMISSION TO M.TECH / M.PLANNING DEGREE COURSE 2015 - 16
1. Name in CAPITAL Letters, beginning from the left; initials at the end of the name.(Please insert one letter in a box)S H A K I R A P V
2. Postal Address D/O YOUSUF HAJI (LATE) SHAKIRA MANZIL ARANGADI Affix KANHANGAD recentPin Code 671315 passport size photo
3 (a) Contact Telephone Number 4. Date of birth in Christian EraSTD Code Land Phone Day Month Year0 4 6 7 2 2 0 4 7 7 6 1 5 0 9 1 9 8 7Mobile No. 9 8 4 6 8 6 2 0 6 6 E mail address,if any. [email protected]
5 Sex Is Keralite Religion Caste Reservation Category Non-CreamyLayer
Female Yes ISLAM MAPPLILA SEBC(OBC) No
6 Is GATE Qualified No
7 Details of Qualifying ExaminationDegree B.TechBranch Computer Sc. & EngineeringUniversity COCHIN UNIVERSITY OF SCIENCE AND TECHNOLOGYName of the College College of Engineering, Trikaripur CETKRIs the College approved by AICTE YesYear of Passing 2009
Semwise Mark/SGPA DetailsSemesters Marks/SGPA Scored Total Marks/SGPASem 1 & 2 1362 1700
Sem 3 890 1050Sem 4 867 1050Sem 5 796 1050Sem 6 823 1050
Total Marks in all Semesters up to and including sem 6 4738Maximum Marks in all Semesters up to and including sem 6 6950
8 Fee Amount 500
9 Whether Physically Challenged No
10 Sponsored Candidate No
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11 Choice of specialisation in the order of preferenceChoice College Specialisation Category
1 KSD Computer Science & InformationSecurity
Non-GATE
DECLARATION(To be filled by the candidate)
I, ............................................................. hereby solemnly and sincerely affirm that the statements made and informationfurnished in this application and also in the enclosures thereof submitted by me are true to the best of my knowledge and belief.Ihereby agree to abide by the rules and regulations of the college,if admitted.
Place: Date: Signature of the Candidate
Note: 1.Late applications, those which do not contain the necessary documents specified in clause of the prospectus and in which any certificate is found defective, will
be rejected.2.Those who have not secured qualification from the universities in Kerala state ,shall produce equivalency certificate at the time of admission/counseling.
List of Enclosures:
Self attested true copy of Engineering Degree certificate and Mark lists.
Self attested true copy of GATE Score card (for Candidates with valid GATE Score) Self attested true copy of non creamy layer certificate for candidates who claim eligibility under SEBC(OBC)/OEC Self attested true copy of Community certificate issued by the Tahsildar for candidates who claim eligibility for reservation under SC/ST quota.
Self attested true copy of professional experience certificate from the Head of the organizations where the candidate is working in case of
those who passed AMIE/AMIETE.
Self attested true copy of Nativity Certificate.
Counterfoil of Chalan after remittance of application fee in any branch of SBT.
Additional Certifiates:
Self attested true copy of Sponsorship Certiciate for candidates applying under the sponsered category.
Self attested true copy of Physical Disability Certificate for candidates who claim eligibility under the Physical Disability quota.
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Instructions to Bank:Please note to enter the Application No and Student name in the mandatory fields while posting the amount in the Current Account.
STATE BANK OF TRAVANCORE Fee Payment Voucher
Bank Copy
Date:............................
Branch:Challan No: To be Filled by Student
Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481.
Application No 22882 Name of Degree: MTECHName of Student: SHAKIRA P VAmount: 500 Commission: 10Name and Address of Student:
D/O YOUSUF HAJI (LATE)SHAKIRA MANZILARANGADIKANHANGAD 671315
Bank Seal
Cashier: Passing Officer:
Mobile Number: 9846862066
Amount in words: Five Hundred and Ten Only
Signature:.................................
Total: 510
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Student Copy
Date:............................
To be Filled by StudentBranch:Challan No:
Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481.
Application No 22882 Name of Degree: MTECHName of Student: SHAKIRA P VAmount: 500 Commission: 10Name and Address of Student:
D/O YOUSUF HAJI (LATE)SHAKIRA MANZILARANGADIKANHANGAD 671315
Bank Seal
Cashier: Passing Officer:
Mobile Number: 9846862066
Signature:.................................
Total: 510
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Orginal Copy
Date:............................
Branch:Challan No:
To be Filled by Student
To be submitted along with the Application _____________________________________
Please credit the amount towards Application Fee to the account of DIRECTORATE OF TECHNICAL EDUCATION Account No. 67179772330 with SBT, Fort Branch,Trivandrum - code - 481.
Application No 22882 Name of Degree: MTECHName of Student: SHAKIRA P VAmount: 500 Commission: 10Name and Address of Student:
D/O YOUSUF HAJI (LATE)SHAKIRA MANZILARANGADIKANHANGAD 671315
Bank Seal
Cashier: Passing Officer:
Mobile Number: 9846862066
Signature:.................................
Total: 510510