1. application b arch - Mookambika Technical Campus

Application No.
A/
Reg. No.
MOOKAMBIKA TECHNICAL CAMPUS
(APPROVED BY COA, NEW DELHI & AFFILIATED TO MG UNIVERSITY, KOTTAYAM)
A Hi -Tech Architectural College with a difference.
Ambika Nagar, Eattapilly, Mannathur, Muvattupuzha
Ernakulam Dt., Kerala. - 686723
0485 2876300, 9496469600, 9447165382, 9447206400
www.mookambika.ac.in
mail@mookambika.ac.in
APPLICATION FOR ADMISSION TO B. ARCH DEGREE COURSE 2013 - 14
1 Name of the Candidate
Please affix your Self
:
attested Passport size
1st Attempt 2nd Attempt 3rd Attempt
2
NATA SCORE
3
ABSTRACT OF THE MARKLIST PLUS TWO
Avarage
Photograph
:
(Please attach an attested copy of the mark list of Plus 2 examination)
4 Reg. No. of PLUS TWO EXAM.
No. of Chances
5 TOTAL % of MARKS in PLUS TWO:
% in Maths:
6 If belongs to SEBC, Give details
Ref. Prospectus 2013 - Commissioner of Entrance Exams - Para 5.4.2 . (Page11 & 12) and annexure - XI (Page 77)
7 Total Annual income
If less than 4.5 lakhs per year, Income Certificate from Village officer should be produced before admission.
Please Refer Prospectus 2013 of Commissioner of Entrance Exams for availing the benifit of SEBC.
8 TC No. and Date
9 Name of School
Marks in Entrance Exam.
Part I
Part II
10 Entrance Examinations
Total
Roll. No. if any
11 Rank in Entrance
FOR OFFICE USE ONLY FOR RANK LIST
PCM % Normalised % Entr. Exam %
Total %
Examinations if any
12 Whether the candidate needs *HOSTEL Accommodation
YES
No
YES
No
* Hostel is with Pure Vegetarian Mess only
13 Whether the candidate needs COLLEGE BUS facility
14 Name of the applicant in full
:
(BLOCK LETTERS) as in certificate
15 Mother Tongue
16 Address for communication
:
:
District & State
:
Pincode
:
17 Date of Birth in Christian era (in figures)
:
(in words)
:
18
Religion/Caste
:
19
Sex
: M/F
21
Nationality:
:
22
23
Nativity
:
a) Name of Parent/Guardian
:
b) Relationship with the applicant
:
c) Address of Parent/Guardian &
:
:
:
Give e-mail address, if any
d) Mobile No: If any
:
:
e) Phone No: Residence (with STD code) :
f) Phone No: Office
:
g) Occupation of parent
:
h) Official Address of parent/Guardian
:
:
:
:
20) Blood Group
Keralite /
Non Keralite
14 Name of the applicant in full
:
(BLOCK LETTERS) as in certificate
15 Mother Tongue
16 Address for communication
:
:
District & State
:
Pincode
:
17 Date of Birth in Christian era (in figures)
:
(in words)
:
18
Religion/Caste
:
19
Sex
: M/F
21
Nationality:
:
22
23
Nativity
:
a) Name of Parent/Guardian
:
b) Relationship with the applicant
:
c) Address of Parent/Guardian &
:
:
:
Give e-mail address, if any
d) Mobile No: If any
:
:
e) Phone No: Residence (with STD code) :
f) Phone No: Office
:
g) Occupation of parent
:
h) Official Address of parent/Guardian
:
:
:
:
20) Blood Group
Keralite /
Non Keralite
EXTRA CURRICULAR ACTIVITIES
1. National Level Participation/Certificates
2. State Level Participation/Certificate
3. District Level Participation/Certificate
4. Other fields of proficiency
DECLARATION
In case I am in the Rank List and I am admitted in SIMAT, Myself along with my parent hereby solemnly declare
that I will neither indulge in any political activities inside the campus nor persuade others to such activities. I also declare
that I will not arrange or attend meetings of any nature that are not permitted by the College Authorities. I further declare
that I will not bring any mobile phone /IPod or any similar devices in the college campus . Further I will never involve
myself in any act of harassment or ragging on any other student either physically or mentally or by words or
deeds throughout my student career.
Date
Signature of the Student
I further affirm that my ward will not indulge in any act which is detrimental to the interest of the college and which
will undermine the discipline. In case any of the above condition is violated, I know that my ward is liable to be dismissed
from the college without any notice.
Date
Office use only
Office use only
Signature of the Parent/ Guardian