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Application No: 22882

Government 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
Pin Code

recent

671315

passport size
photo

3 (a) Contact Telephone Number

STD Code

4. Date of birth in Christian Era

Land Phone

0 4 6 7 2

Mobile No. 9 8 4 6 8 6 2 0 6 6
5

Day
1

Month
5

Year

E mail address,if any.

MUKUNHI@GMAIL.COM

Sex

Is Keralite

Religion

Caste

Reservation Category

Female

Yes

ISLAM

MAPPLILA

SEBC(OBC)

Non-Creamy
Layer

Is GATE Qualified

Details of Qualifying Examination

No

No

Degree

B.Tech

Branch

Computer Sc. & Engineering

University

COCHIN UNIVERSITY OF SCIENCE AND TECHNOLOGY

Name of the College

College of Engineering, Trikaripur CETKR

Is the College approved by AICTE

Yes

Year of Passing

2009
Semwise Mark/SGPA Details

Semesters

Marks/SGPA Scored

Total Marks/SGPA

Sem 1 & 2

1362

1700

Sem 3

890

1050

Sem 4

867

1050

Sem 5

796

1050

Sem 6

823

1050

Total Marks in all Semesters up to and including sem 6

4738

Maximum Marks in all Semesters up to and including sem 6

6950

Fee Amount

500

Whether Physically Challenged

No

10 Sponsored Candidate

No

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11 Choice of specialisation in the order of preference

Choice

College

Specialisation

Category

KSD

Computer Science & Information

Non-GATE

Security
DECLARATION
(To be filled by the candidate)

I, ............................................................. hereby solemnly and sincerely affirm that the statements made and information
furnished in this application and also in the enclosures thereof submitted by me are true to the best of my knowledge and belief.I
hereby 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

Branch:
Challan No:

Bank Copy

To be Filled by Student
Date:............................
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 Student:

SHAKIRA P V

Amount:

Name of Degree:

Commission:

500

10

Name and Address of Student:

D/O YOUSUF HAJI (LATE)
SHAKIRA MANZIL
ARANGADI
KANHANGAD 671315
Mobile Number: 9846862066

MTECH

Total:

510

Bank Seal

Amount in words: Five Hundred and Ten Only

Signature:................................. Cashier:

Passing Officer:

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Branch:
Challan No:

To be Filled by Student

Student Copy

Date:............................
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 Student:

Name of Degree:

SHAKIRA P V

Amount:

500
Name and Address of Student:
D/O YOUSUF HAJI (LATE)
SHAKIRA MANZIL
ARANGADI
KANHANGAD 671315

Commission:

10

MTECH
Total:

510

Bank Seal

Mobile Number: 9846862066

Signature:................................. Cashier:

Passing Officer:

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Orginal Copy

Branch:
Challan No:

To be Filled by Student

To
be submitted along with the Application
_____________________________________

Date:............................

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:

Name of Student:

SHAKIRA P V

Amount:

Commission:

500
Name and Address of Student:

10

D/O YOUSUF HAJI (LATE)

SHAKIRA MANZIL
ARANGADI
KANHANGAD 671315

MTECH
Total:

510

Bank Seal

Mobile Number: 9846862066

Signature:................................. Cashier:

Passing Officer: