APPLICATION FORM

FOR ADMISSION TO DIPLOMA COURSES AT

GOVERNMENT POLYTECHNIC, DAMAN

YEAR: 2019-20

Personal Details - Step 1 of 3

Fill up application form with CAPITAL LETTERS as per S.S.C.E. Leaving Certificate/ Marksheet

Name of Canditate *

Choose Photo *

Allowed file formats:- .png, .jpg Maximum size:- 200 KB

Father's Name *

Mother's Name *

Category Applied for *

GEN
SC
ST
OBC
PH
DNH
EWS
Others

Gender *

Date 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 *

Village

District *

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? *

Mark's Obtained in S.S.C. Examination or it's Equivalent :

Sr. No.

Name of Subject

Marks out of

Marks Obtained

Mathematics

Marks Out of (Mathematics) *

Marks Obtained (Mathematics) *

ii.

Science

Marks Out of (Science) *

Marks Obtained (Science) *

iii.

English

Marks Out of (English) *

Marks Obtained (English) *

iv.

Social Science

Marks Out of (Social Science) *

Marks Obtained of (Social Science) *

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)) *

TOTAL

Marks Out of (Total Subject) *

Marks Obtained (Total Subject) *

Choice of Courses

S.No.

Name of Course

Preference Number

Diploma in Civil (CE)

Preference for Civil (CE) *

Diploma in Mechanical (ME)

Preference for Mechanical (ME) *

Diploma in Chemical (CHE)

Preference for Chemical (CHE) *

Diploma in Information Technology (IT)

Preference for Information Technology (IT) *

Diploma in Electrical (EE)

Preference for Electrical (EE) *

Diploma in Computer (COE)

Preference for Computer (COE) *

Diploma in Plastic Energy (PE)

Preference for Plastic Energy (PE) *

Details of Passing SSC Examination or its equivalent

Exam Seat No.

Name of Exam Board

Name of School/Institute from which passed

Month & Year of Passing

No. of attempts in which passed

Exam 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: *

Subject 1 *

Subject 2

Subject 3

Have you represented U.T. of Daman & Diu in any Sport/Game in any Nation Event? if so, give details *

Brief 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 *

Brief detail about the service you rendered in NCC/ACC/Scouts and Guides activities *

Have you Sought admission in this Diploma Institute before *

If yes, give details

Branch *

Registration No. *

Details examination passed after S.S.C. Exam or its equivalent :

Have you applied for any other Course in other Institute? *

If yes, give details

Details of application in other Institute *

Undertaking and Declaration

a) 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 *