GENERAL

Government of Kerala

OFFICE OF THE COMMISSIONER FOR ENTRANCE EXAMINATIONS

Housing Board Buildings, Santhi Nagar, Thiruvananthapuram - 695 001.

APPLICATION FOR ADMISSION TO PROFESSIONAL DEGREE COURSES, KERALA 2013 Application No.

1115201
SHARANYA V Engineering,Medical,MBBS & BDS (NEET-UG 2013) KASARAGODE Female 21/01/1995 18 Keralite Indian NA NO SHARANAM MANIYIL,CHATHANKAI,CHANDRAGIRI P O,671317 SHARANAM MANIYIL,CHATHANKAI,CHANDRAGIRI P O,671317 9747371496 -Phone Number Taluk 04994236194 -Email ID District vsharanya21@gmail.com -2(a) NEET UG Reg.No: 1089648 QH,NA
KERALA BOARD OF PUBLIC EXAMINATIONS

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Name of Applicant Course(s) opted Centre of Examination Gender Date of Birth Age as on 31/12/2013 Nativity Citizenship Income Special Reservation(s) Permanent Address Communication Address Mobile Number Village

15 Qualifying Examination 16 Board 17 Subjects Studied 18 Studied Sanskrit 19 Category Claim & Subcaste 20 Claim Inter-caste 21 Person with Disability

PHY,CHE,MATHS,BIO NO NA,NA NO 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: 22. Candidates Identification: 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 : 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 Signature of Candidate : Place: Date:

(Office Seal) 23. Payment Details : Pay Mode Security Card Card Sl. No. 5178650 Amount 700

CERTIFICATE CHECK LIST (Put Nativity Certificate

in the appropriate squares if you enclose the following documents) Course Certificate NEET UG 2013 Confirmation Page

OFFICE USE ONLY Nativity Comm. Res Special Res. Group PWD Others Remarks:

IT Services: NIC Kerala

IP Address:'.117.213.29.238

Final Submission Done on:16-01-2013 16:28:34

Printed on:20-01-2013 18:07:00

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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

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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 :
* Strike out whichever is not applicable.

(Office Seal)

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