APPLICATION FORM FOR ADMISSION TO DIPLOMA COURSES AT GOVERNMENT POLYTECHNIC, DAMAN YEAR: 2019-20 Personal Details - Step 1 of 3Fill up application form with CAPITAL LETTERS as per S.S.C.E. Leaving Certificate/ MarksheetName of Canditate *Choose Photo *Allowed file formats:- .png, .jpg Maximum size:- 200 KB Father's Name *Mother's Name *Category Applied for *GENSCSTOBCPHDNHEWSOthersGender *SelectMaleFemaleOthersDate of Birth: (DD/MM/YYYY) as per Leaving Certificate *Place of Birth (as per Leaving Certificate)Email *Aadhar Card *Full Address with Pin Code & Phone Mobile. (For Correspondence) House No./Flat No. *Building/House Name *Street/Sheri/Lane *VillageDistrict *State *Pin Code *Parent's Mobile Number *Mobile Number *Father / Guardian (Name,Occupation and Address) :Name *Occupation *Address *Parents Annual Income from all sources *Relationship with Guardian *Do you belong to Scheduled Caste/Tribe or OBC? *--Select--YesNoNextMark's Obtained in S.S.C. Examination or it's Equivalent :Sr. No.Name of SubjectMarks out ofMarks Obtainedi.MathematicsMarks Out of (Mathematics) *Marks Obtained (Mathematics) *ii.ScienceMarks Out of (Science) *Marks Obtained (Science) *iii.EnglishMarks Out of (English) *Marks Obtained (English) *iv.Social ScienceMarks Out of (Social Science) *Marks Obtained of (Social Science) *v.Subject (v) *Marks Out of (Subject (v)) *Marks Obtained (Subject (v)) *vi.Subject (vi)Marks Out of (Subject (vi)) *Marks Obtained (Subject (vi)) *vii.Subject (vii)Marks Out of (Subject (vii)) *Marks Obtained (Subject (vii)) *viii.Subject (viii)Marks Out of (Subject (viii)) *Marks Obtained (Subject (viii)) *TOTALMarks Out of (Total Subject) *Marks Obtained (Total Subject) *Choice of CoursesS.No.Name of CoursePreference Number1Diploma in Civil (CE)Preference for Civil (CE) *2Diploma in Mechanical (ME)Preference for Mechanical (ME) *3Diploma in Chemical (CHE)Preference for Chemical (CHE) *4Diploma in Information Technology (IT)Preference for Information Technology (IT) *5Diploma in Electrical (EE)Preference for Electrical (EE) *6Diploma in Computer (COE)Preference for Computer (COE) *7Diploma in Plastic Energy (PE)Preference for Plastic Energy (PE) *Details of Passing SSC Examination or its equivalentExam Seat No.Name of Exam BoardName of School/Institute from which passedMonth & Year of PassingNo. of attempts in which passedExam Seat No.Name of Exam Board *Name of School/Institute from which passed *Month & Year of Passing *No. of attempts in which passed *Have you passed SSC Exam or its equivalent with Technical Subject?if so, give the name of the Technical Subjects Offered: *SelectYesNoSubject 1 *Subject 2Subject 3Have you represented U.T. of Daman & Diu in any Sport/Game in any Nation Event? if so, give details *SelectYesNoBrief detail about represention U.T. of Daman & Diu in any Sport/Game in any Nation Event *Have you rendered service in NCC/ACC/Scouts and Guides activities? if so, give details *SelectYesNoBrief detail about the service you rendered in NCC/ACC/Scouts and Guides activities *Have you Sought admission in this Diploma Institute before *SelectYesNoIf yes, give detailsBranch *Registration No. *Details examination passed after S.S.C. Exam or its equivalent :Have you applied for any other Course in other Institute? *SelectYesNoIf yes, give detailsDetails of application in other Institute *PreviousNextUndertaking and Declarationa) I undertake to join the National Cadet Corps if called upon by Principal to do so. b) I hereby undertake, if admitted, to confirm to the Rules and Regulations at present in force or that may thereafter be made for the Govt. Polytechnic, and that so long as I am a student of the Polytechnic, I will do nothing either inside or outside the Polytechnic that will interfere with its orderly governance and discipline. c) I hereby declare that I have not been admitted to any Polytechnic previously. d) I hereby declare I have not been debarred from appearing for any examination by any Govt. Constituent Statutory Examination Authority in India e) I promise not to harm any other students in any form and will not in any way be involved in any kind of ragging activities. f) I hereby declare the Institution (Government Polytechnic, Daman ) will not in any way be held responsible accidents/injuries during the Institution Practicals/Training in Industries/Educational Tours.Place *Date *Signature of Candidate *Allowed file formats:- .png, .jpg Maximum size:- 200 KB CommentSubmit