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GENERAL
SIGN THIS FORM, AFFIX PHOTO, ATTEST AND SEND TO CEE OFFICE

Application No: 1184178

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 2012

1. 2. 3. Courses Opted for Centre chosen for Entrance Examination Name of Applicant Engineering PATHANAMTHITTA RIYA MARY REJI

4. CANDIDATE'S IDENTIFICATION (Please affix recent passport size photograph (same as the uploaded one) on the right side box. Also attest this photograph by the Principal / Head of the Institution where the candidate has studied / is studying or by a Gazatted Officer.) I certify that the Photo is that of (write name of Applicant): ............................................... Name & address of the Attesting Officer: Affix a recent passport size photograph identical to the uploaded one Attesting Officer to sign over the photograph

(Office Seal) 5. 6. 7. 8. 9a 9b 10. 11. 12 Gender Date of Birth Nativity State of Permanent Residence Name of Parent / Guardian Relation Citizenship Religion Details of Income Certificate (a) Income (b) Village (c) Taluk (d) District 13 a. Permanent Address INR 5,40,000.00 Ayirur Ranni Pathanamthitta KAIPPALLIL KOLAKOTTU KOTTATHOOR P O AYROOR PATHANAMTHITTA KERALA Pincode:- 689614 KAIPPALLIL KOLAKOTTU KOTTATHOOR P O AYROOR PATHANAMTHITTA KERALA Pincode:- 689614 Female 05/07/1994 Keralite Kerala REJI K MATHEW FATHER Indian Christian Caste ORTHODOX Age as on 31/12/2012 18

13 b. Address for Communication

IT Services: NIC Kerala

Date:30/01/2012

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13 c

Contact Details 04735230866 Mobile No 9495238409 E-mail Id riyamaryreji@gmail.com Kerala Higher Secondary Appeared/Appearing BOARD 8070629, 2012 ST BEHANANS HIGHER SECONDARY SCHOOL VENNIKULAM KERALA Physics Chemistry Maths Biology NO Not Applicable, Not Applicable Not Applicable

Land Phone with STD Code

14 a. Details of Qualifying Examination 14 b. Passed/Appeared/Appearing 14 c. Board/University 14 d. Register No. & Year 14 e. Institution 15. 16. 17. 18. 19. Subjects studied at Higher Secondary Level Studied Sanskrit Reservation Category Reservation under AI/JW/OEC with father / mother belonging to SC/ST or SEBC 20. 21. 22. 23 Whether SC/ST claim rejected previously Special Reservation Person with Disabilities Details of Application Fee

Child of an inter-caste married couple NO

NO NO NO Payment Method Security Card

Card Serial No 2195970

Amount 700

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Application No: 1184178

CERTIFICATE TO PROVE NATIVITY FOR KERALITES

CERTIFICATE OF BIRTH/RESIDENCE
( To be issued by 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 Engineering/Medical/Agriculture Entrance Examination(s) 2012 and he/she | his/her father/mother Shri/Smt ... House....Village.. District ., ... was born in Kerala.

OR*
Certified that, Shri/Smt /Kum.... ,an Applicant for the Engineering/ Medical/Agriculture Entrance Examination(s) 2012 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 : Name and Designation : Taluk :......... District :.......... Place : Date : (Office Seal)

* Strike out whichever is not applicable

OR*
CERTIFICATE SHOWING SCHOOL STUDIES IN KERALA FROM STANDARD VIII TO XII
( To be issued by Head of the School where the applicant has complete his/her studies/is studying in Standard XII in Kerala State.If the candidate has studied in different schools,appropriate certificates to that effect may be produced before the Head of the institution where the candidate has studies/is studying in Class XII, who will issue this certificate.)

CERTIFIED that Shri/Smt /Kum...., an Applicant for the Engineering/Medical/Agriculture Entrance Examination(s) 2012 son/daughter of Shr/Smt ...... of......(address) ,has undergone/ is undergoing his/her school studies in Standards VIII TO XII in the educational institution(s) situated in Kerala State.

Signature of the Head of the School: Name : Designation : Name of Institution :......... District :.......... Place : Date : (Office Seal)

OR*
In the absence of above certificates, 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.

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Application No: 1184178

CERTIFICATE TO PROVE NATIVITY FOR NON-KERALITES (Category I)

A Non-Keralite candidate who has undergone school in Standards XI & XII in Kerala and who is son/daughter of Non-Keralite parent(s) who are not domiciled in the State of Kerala but served/serving for Govt. of India/ Govt. of Kerala should produce the following two certificates. CERTIFICATE TO BE ISSUED BY THE EMPLOYER
(For Non-Keralite parents working under Govt. of India/ Govt. of Kerala only)

Certified that, Shri/Smt /Kum.... father/mother of Shri/Smt .......,a candidate for Engineering/Medical/Agriculture Entrance Examination(s) 2012 had/has been employed as ...(Designation), fromto (Date,Month & Year) in ... (Name of Office with District and State). Signature: Name : Designation & Address :......... Place : Date : (Office Seal)

AND
CERTIFICATE SHOWING SCHOOL STUDIES IN KERALA IN STANDARDS XI & XII ( To be issued by Head of the School where the candidate has studied/is studying for the Higher Secondary or equivalent Examination in Kerala State) CERTIFIED that Shri/Smt /Kum...., an Applicant for the Engineering/Medical/Agriculture Entrance Examination(s) 2012 son/daughter of Shr/Smt has studied for not less than 2 (two) years immediately preceding his/her appearance for the qualifying examination in ....(Name of Institution), an educational institution in Kerala State. Signature of the Head of the Institution: Name : Designation : Address :......... Place : Date : (Office Seal)

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Date:30/01/2012

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Application No: 1184178

CERTIFICATE TO PROVE NATIVITY FOR NON-KERALITES (Category II)

A candidate who is not a 'Keralite' or 'Non-Keralite (Category I)' should produce the following certificate. [Non-Keralite (Cat-II) candidates are eligible for admission to the Engineering courses in management quota seats in self-financing institutions sponsored by Government and in the Government seats in private self-financing colleges only]. CERTIFICATE OF COMPLETION OF QUALIFYING EXAMINATION
(To be issued by the Head of School where the applicant has completed/ is studying for the Qualifying Examination)

CERTIFIED that Shri/Smt /Kum.., an applicant for Engineering/Medical/ Agriculture Entrance Examination(s) 2012, who is the son/daughter of Shri./Smt. of (address) has studied/is studying for his/her Qualifying Examinations (Standards XI and XII) in(institution) situated in..State in India. Signature of the Head of the Institution: Name : Designation : Address :......... Place : Date : (Office Seal)

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Application No: 1184178

Income Certificate*
No. Village Office : Date :

Shri/Smt. , residing at house, village taluk, district had submitted an application** on date to issue an Income Certificate for purpose. He/She had declared that his/her annual income is Rs. On my enquiry, I certify that his/her annual family income is as per given below. The total members in the family are out of which are employed, are studying and are unemployed.
Sources of Income Members Father Mother Children Income from land Salary/Pension (Other than Family pension)*** Business Wages from labour Income from persons abroad Rents Others Total

Total amount in figures: Total amount in words: In case, having more than 3 children, amount to be deducted for excess children: .... Balance amount in figures: .. Balance amount in words:

Signature: Office Seal ______________________________________________________

* Annual Income of the previous financial year to the date of application should be considered. ** The person to which Income Certificate is sought must be specified. *** In the case of permanent employees, existing DA should be calculated with the basic pay for determining the annual family income.

Name & Designation:

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Date:30/01/2012

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COMMUNITY CERTIFICATE
(For Scheduled Caste & Scheduled Tribe Candidates)

1.This is to certify that, Shri/Smt /Kumari.... Son/Daughter of ofHouse ....Village/Town.. Taluk. District of kerala State belongs to the... Caste/*Tribe which is recognized as a Scheduled Caste/ Scheduled Tribe under :-

The Constitution Ammendment (Scheduled Castes) Order,1950;The Constitution Ammendment (Scheduled Tribes) Order,1950 [As amended by the Scheduled Castes and Scheduled Tribes Orders(Amendment)Act,2002)/ The Constitution (Scheduled Castes) Orders (Second Amendment) Act,2012]

Certify that, Shri/Smt./Kumari.(name of person) Son/Daughter ofofHouse ....Village/Town.. Taluk. District is a member of Malai Araya Christian family converted to Christianity from Hindu Malai Arayan Community, which is included in the list of Scheduled Tribes.

2. Shri/Smt /Kumari....and his/her* family ordinarily resides(s) in Village/Town,of ........District of Kerala State.

Signature of Tahasildar : Name : Place : Date :

(Office Seal) _________________________________________________________________________________________________

* Please delete the words / clause which are not applicable.

Note: 1. The term ordinarily resides used here will have the same meaning as in Section 20 of the Representation of the Peoples Act, 1950. 2. In the case of X'ian converts from SC who have subsequently embraced Hinduism should get the following certificate recorded by the 'Tahasildar' below the community certificate.'The certificate is issued after observing the guidelines issued in Government Circular no. 18421/E2/87/SC/ST/DD.Dated 15-12-1987'. 3. Issue of Community Certificate to Scheduled Caste / Scheduled Tribe will be regulated by Act II of the Kerala (Scheduled Caste & Scheduled Tribe) Regulation of Issue of Community Certificate Act 1996. 4. Certificate to persons belonging to Malai Arayan Community (ST) converted to Christianity should be in this form.

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Date:30/01/2012

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COMMUNITY CERTIFICATE
(These Certificates are required only if the candidate claims reservation under the Socially and Educationally Backward Classes/Other Eligible Communities/Anglo Indian/Jews)
[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./Kumari , Son/Daughter of Shri/Smt House .... village/Town..... Taluk District . of Kerala State belongs to the .... 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,G.O(MS) No.95/08/SCSTDD dated 06-10-2008 and subsequent amendments, thereof.

Signature of Village Officer : Name : Designation and Address : Place : Date :

(Office Seal) _________________________________________________________________________________________________

Note: (i). Candidate claiming reservation under SEBC, should furnish both the Community & Income Certificates given below in support of the claim. Candidates belonging to Anglo Indian/Jew communities need produce only the Community Certificate given below for this reservation. (ii). Son/Daughter of Inter-Caste married couple, claiming communal reservation need produce only the 'Inter-Caste Marriage Certificate' in the proforma given in Annexure XV of the Prospectus. Such candidate need not produce Community & Income Certificate for claiming communal reservation.

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Application No: 1184178

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) 2012, 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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Date:30/01/2012

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List of Enclosures

1. ........................................................... 2. ........................................................... 3. ...........................................................

4. ........................................................... 5. ........................................................... 6. ...........................................................

DECLARATION (To be filled by the candidate) 1. I hereby declare that I have read the various clauses in the Prospectus for Admission to Professional Degree Courses 2012 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 examination, action can be taken against me by the Commissioner for Entrance Examinations.

Signature of Parent/Guardian Place: Date:

Signature of the Applicant Place: Date:

For Office use Only Item Group Nativity Communal Res. Spl. Res PWD Others Signature of Officer: S.O.1 Final Remarks: S.O.2 AD RD Remarks 1 Remarks 2

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Date:30/01/2012

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Application No: 1184178

CHECK LIST
1. The candidate should see that, he/she submits Print out of application form COMPLETE in all respects to the office of the Commissioner for Entrance Examinations on or before 5 pm on 15.02.2012. 2. Photographs: Photograph affixed in Page 1 of the Main Application form, which has to be attested by a Gazetted Officer or by the Head of Institution where the candidate is studying/has studied for the qualifying examination. If the photograph is not attested, the Application will be rejected. The photograph should be identical to the uploaded one without which the application will be rejected. 3. Certificates/Documents to be obtained in the Application form/to be attached (as applicable): (a) Proof of Nativity: Keralite: Any of the certificates mentioned under 12.1 (a) or 12.1 (b) in the Printout of the Application form OR 12.1 (c) to be attached and self-attested. If copy of SSLC/Passport/Birth Certificate of father/mother of the candidate is enclosed, supporting document to establish the relationship between the candidate and father/mother, whose certificate is attached, should also be enclosed. For Keralite-AIS: Certificate from competent authority, Non-Keralite (I): Non-Keralite (II): Certificates 12.2 (a) and 12.2 (b) in the Printout of the application form. Certificate 12.3 in the Printout of the application form.

(b) Course Certificate: Course Certificate to be obtained by all candidates (APPEARED / APPEARING for the qualifying examination) Candidates who have passed Plus Two/qualifying examination can attach a self-attested copy of mark list / pass certificate to prove their academic eligibility if applying for Medical Courses, instead of course certificate. B.Sc. Graduates should enclose copy of the mark lists of all parts of B.Sc. of all years along with the mark lists of Higher Secondary / equivalent examination. 4. Income Certificate: Candidates who wish to be considered for any kind of scholarship / fee waiver schemes to be announced by the Government shall enclose Income Certificate in the format provided. 5. Demand Draft if opting DUBAI Centre: Attach additional DD for Rs.10000/- as centre fee along with the Application Form. 6. Signature: Ensure that the parent and the candidate have signed the declaration in the application form, in the space provided. 7. Arrangement of the Completed Application form: (a) Application form (b) Income Certificate (if enclosed) (c) Attested copies of relevant certificates (d) Chalan authorized by SBT authorities / Demand Draft 8. Envelope: Use A4 size envelope to send completed application form to the office of the Commissioner for Entrance Examinations. The envelope should be superscribed with 'ADMISSION TO PROFESSIONAL DEGREE COURSES, KERALA 2012'. 9. Submission of Application: The application form complete in all respects, should be sent by Registered Post/Speed Post, or by hand delivery, so as to reach the CEE on or before 5 pm on 15.02.2012. 10. BELATED APPLICATIONS WILL BE REJECTED. The Office of the Commissioner for Entrance Examinations will not be responsible for postal delay or any mishaps. Candidates are therefore advised to apply in time.

IT Services: NIC Kerala

Date:30/01/2012