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APPLICATION FORM FOR DIRECT ADMISSION IN

ENGINEERING COURSES OF POLYTECHNICS IN RAJASTHAN

ADMISSION 2011-2012

Admission Merit No. ___________

1. NAME OF CANDIDATE (IN ENGLISH) : __________________________________________________________________________________

(IN HINDI) : __________________________________________

__________________________________________

2. FATHERS / HUSBANDS NAME : __________________________________________

3. MOTHERS NAME : __________________________________________4. POSTAL ADDRESS :___________________________________________

(Do not repeat name again)

___________________________________________

Dist. _________State_________Pin code___________

5. SEX :

6. DATE OF BIRTH :

7. CATEGORY OF RESERVATION :

REGILION :

9. Whether you want admission under Tuition fee waiver scheme (TFWS) :

Registration No. Form No.

Affix Passport size

Photograph of the

candidate duly signed

by candidate and

attested by the

principal or his

nominee

MALE FEMALE

1 HINDU

2 MUSLIM

3 SIKH

4 CHRISTIAN

5 OTHERS

YES NO

1 GENERAL

2 SC

3 ST

4 OBC

5 SBC

6 MP

7 PH

8 OTHERS

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10. ACADEMIC RECORD:SECONDARY / EQUIVALENT EXAM Sr. SECONDARY / EQUIVALENT EXAM Details of ITI Certificate Holder

Max.

Marks

Marks

Obt.

Optional Subjects Max.

Marks

Marks

Obt.

Max. Marks

Maths Marks Obt.Maths

Physics Name of Engg. Trade

Science Chemistry Duration

Aggregate of All

Subjects

Aggregate including

compulsory subjects

Year of passing

Name of Board &

Year of Passing

Name of Board &

Year of Passing

Name of Institute

Marks Improved? Yes / No Marks Improved? Yes / No Marks Improved? Yes / No

It is certified that

(i) All the entries in this form have been made by me and all are correct. I shall be responsible for anyincorrect information provided by me.

(ii) I have read all the information & rules given in the brochure. I shall abide by all the rules of thePolytechnic, Hostel and Board of Technical Education Rajasthan.

Signature of the Candidate

DECLARATION BY FATHER / GUARDIAN

I ________________________________________ ( Fathers / Guardians Name) of the Candidate

Sh. / Ms. ____________________________________ take all the responsibilities for his/ her conduct &

maintainance 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 Father / Guardian

FOR OFFICE USE

Sr. No. Criteria Remark Signature

1 Eligibility

2 Marks & Date of Birth

3 Category Reservation

4 Medical Certificate

5 Branch Allotted

6 College Allotted

7 Allot Category

Fees Deposited

Receipt No.

DD No. & Bank / Cash

Admitted / Not Admitted