Duly filled in Application Form along with attested copies of supporting documents is to be submitted

at the receiving centres ie. LBS CENTRES and selected POLYTECHNICS IN KERALA, after filing
personal data, academic data and options online, within the time limit.

APPLICATION FORM FOR GENERAL CANDIDATES

Application Number Registration ID
(To be filled in by the candidate)

LBS Centre for Science & Technology

Nandavanam, Palayam, Thiruvananthapuram - 695033

APPLICATION FOR ADMISSION TO

B. Ed. DEGREE COURSES, KERALA, 2010
Instructions for filling each item of the Application Form are given. Please read the prospectus carefully before filling in the
Application Form. No item should be left unfilled. The item, which is not applicable to the candidate, should be filled as “Not
Applicable [NA]”
Option Stream Code
Stream (s) opted for B.Ed. 1
1 (Candidates can opt more than
one subject, if eligible.) 2
3
Name of Applicant
2 (in BLOCK letters, initials last)
a. Name of b. Name of
3
father Mother

4 CANDIDATE’S IDENTIFICATION
(Please get attested by signing over the photo by a Gazetted Officer / Head of the
Institution, where the candidate has studied )
I CERTIFY that the photo is that of ……………………………………………………. Please paste
a recent
passport size
----------------------------------------------------------------------------- photograph
Name & address of the
of the Attesting applicant
Officer with office -----------------------------------------------------------------------------
seal
-----------------------------------------------------------------------------

5. Address for Communication (in BLOCK letters): Contact Telephone Numbers & Email id
------------------------------------------------------------------------------------- a. Land Phone

------------------------------------------------------------------------------------- with STD code : --------------------------------------------------

------------------------------------------------------------------------------------- b. Mobile [If any] : --------------------------------------------------

------------------------------------------------Pin Code------------------------ c. Email id [If any] :---------------------------------------------------

6. Sex 7(a) Religion ( b) Caste

(c) Communal Reservation
EZ/ MU / BH / LC/ BX/OEC/ANGLO INDIAN – JEW / NA ( Write suitable code)
Day Month Year
Date of
8. 9. Nationality:
Birth

Whether son/daughter of inter-caste married couple : (write ‘YES’ or ‘NO’. If ‘YES’, attach copy
10
of certificate in the format in Annexure IX of Prospectus)
Whether claiming reservation under Defence Quota : (write ‘YES’ or ‘NO’). If ‘YES’, attach
11
copy of certificate in the format in Annexure X(a) of Prospectus)
Whether claiming reservation under Tamil Linguistic Minority : (write ‘YES’ or ‘NO’). If ‘YES’,
12
attach attested copy of certificate in the format in X(c) of Prospectus)
Whether claiming reservation under Kannada Linguistic Minority : (write ‘YES’ or ‘NO’ , If
13
‘YES’, attach attested copy of certificate in the format X(c) of Prospectus)
Whether claiming reservation under ‘Persons with disabilities’ Quota : (write ‘YES’ or ‘NO’, If
14
‘YES’, attach copy of certificate as mentioned in clause 4.4 of Prospectus)
Whether holder of NCC Certificate at Degree level : ( write ‘YES’ or ‘NO’, If ‘YES’, attach
15
attested copy of relevant certificate)
Whether holder of NSS Certificate at Degree level : ( write ‘YES’ or ‘NO’, If ‘YES’, attach
16
attested copy of relevant certificate)
 17 Whether qualified as per the examinations under 10+2+3 pattern : (write ‘YES’ or ‘NO’)

18 Details of Qualifying examination

Under Graduate level. (Please put √ mark in the relevant column as applicable)
a. (i) B.A. (ii) B. Sc (iii) Degree in Vocational / Specialized Courses
c. Scheme
b. Name of the University [Regular / others]
Specify.

d. Main Subject(s) * e. Subsidiaries

Marks Exam. details

f. Details of marks g. Class / Division
Awarded Maximum Reg: No Year obtained

(i) Part I (English)

(ii) Part II (Second Language)

(iii) Part III (Main) h. No. of chances

(iv) * -do-

(v) * -do-

(vi) (Subsidiary I)

(vii) (Subsidiary II)

Grand Total for Parts I, II and III. Awarded Maximum
(viii) [Total of items (i) to (vii) ]

* In case of Double Main / Triple Main candidates. [ They should attach ‘Eligibility certificate, as per Clause 5.2.1 of the
Prospectus ]
If double/triple main for Degree or Vocational/Specialized course for Degree, whether
i. Eligibility certificate produced. (Write YES /NO or else NA).
19. Post Graduate Level. (Please put √ mark in the relevant column as applicable).

a. Subject MCA M.A. M. Sc. M.Com.

c. Scheme
b. Name of the University [Regular / others]
Specify.
d. Marks secured Maximum Marks e. Class / Division f. Number of chances
obtained

20 Specify your academic eligibility to apply for the above subject by putting ‘√ ‘ mark against any of the following.

a. Based on B.A. / B. Sc. / B. Com. / Other Degree.

b. Based on B. Sc. Degree and Master’s Degree.

c. Based on Master’s Degree.

If qualifying examination is passed from Universities outside Kerala, whether Eligibility

21
Certificate is produced. Write ‘YES’ or ‘NO’.

22. DECLARATION
1. I hereby declare that I have read the various clauses in the Prospectus for Admission to B. Ed. Degree courses, 2010 and the
instructions carefully and I agree to abide by them.
2. 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
admission , action can be taken against me by the Director of Collegiate Education/Director LBS Centre.

Signature of the Applicant

Place :…………………………

Date :…………………………. Signature of the Parent/Guardian

 23. Nativity. Candidate should be an Indian citizen of Kerala origin. All candidates should obtain any one of the certificates given
below ((a), (b), (c) (as applicable) to him/her as proof of nativity. In the absence of a certificate to prove nativity of the candidate, the
application will be rejected.

(a) CERTIFICATE SHOWING STUDIES IN KERALA FROM STANDARD XI / EQUIVALENT

(To be issued by the Head of institution where the applicant has completed his/her Graduation / Post Graduation in Kerala State. If the candidate
has studied in different institutions, appropriate certificates to that effect may be produced before the Head of the Institution where the candidate
has studied for Graduation / Post Graduation, who will issue this certificate.)

CERTIFIED that Shri/Smt./Kum…….………………………………………………………………………, an applicant for B.Ed.

admission 2010, son/daughter of Shri./Smt. ………………………….………………..………………..….………..…. of
…………………………………………………………………………………………... (Address) has undergone his/her studies from
XI to Degree / Post Graduation level in the educational institution(s) situated in Kerala State.

Place : Signature of the Principal : ……………………………..……………

Date : Name : …………………………..………………
Designation : …………………………………..………
Name of Institution : ……………………………..……………
(Office Seal)

(b) CERTIFICATE OF BIRTH

(To be issued by the Village Officer / Tahsildar / any other authority in the local body competent to register birth in Kerala State)

CERTIFIED that Shri/Smt./Kum……………………………………, is an applicant for the B.Ed admission, 2010 and that he/she |
his/her father/mother Shri/Smt…………..………………………………………………….…………………… House
…………….…………………… Village…………….…………….. District …..……………….……………….…… was born in Kerala.

OR*

(c) CERTIFICATE OF RESIDENCE

CERTIFIED that Shri/Smt./Kum……………………………….……….……………, an applicant for the B.Ed. admission, 2010 has
been a resident of the Kerala State for a period, not less than 5 years within a period of 12 years.

Signature of the Village Officer / Tahsildar /Birth Registering Authority :

Place : Name and Designation :
Date : Taluk :
(Office Seal) District :

*Strike out whichever is not applicable.

In the absence of (a) or (b), or (c) 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 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 showing the relationship between the candidate and the person (father or mother) whose certificate has been produced.
(iii). Birth certificate of candidate or his/her, father/mother showing the place of birth in Kerala with corroborative evidence showing the
relationship between the candidate and the person (father or mother) whose certificate has been produced.
 25 (a): COMMUNITY CERTIFICATE
(These Certificates are required only if the candidate claims reservation under the socially and Educationally Backward Classes / Other Eligible Communities.
As per Clause 4.1.2 [b] of the Prospectus)
[Note: In case, where the Community is noted only as, ‘Latin Catholic’ or ‘Latin Christian’ in the SSLC and reservation under ‘Latin Catholic Other than Anglo
Indian’ QUOTA is sought, a Certificate from the Village Officer to the effect that the candidate belongs to ‘Latin Catholic Other than Anglo Indian’ or
‘Latin Christian Other than Anglo Indian’ should be obtained in the COMMUNITY CERTIFICATE].

CERTIFIED that Shri/Smt./Kum. …….……………………….……………………………..……………………………. son/daughter of

Shri/Smt…………………………………………………………….…………… House …………………………..…………………………
Village …………………………………………………..………. Taluk ……………………………………………………………… District
………………………………..……….. of Kerala State, belongs to ……………………………………….…….………… caste
………………………………….. religion, which is included as O.E.C. / Socially and Educationally Backward Class as per G.O(P)
208/66 dated 02-05-1966 and subsequent amendments, thereof.

Signature of the Village Officer:

Place: Name:
Date : (Office Seal) Designation & Address:
ANNUAL FAMILY INCOME: Income certificate is to be produced by : Candidates who claim communal reservation under SEBC /
OEC category (except children of inter-caste married couples)
25 (b): INCOME CERTIFICATE
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ÄàÏÄß : …….…………………………….…
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Item Admitted Rejected Remarks 1 Remarks 2

Subject Codes
Nativity
Communal
Res.
Spl. Res.
PWD
Signature of officer: S.O.