5/19/2017 regn.calicut.nielit.in/MTechstudentview.aspx?

sid=88

NIELITCALICUT
CommonApplicationFormforM.TechinEmbeddedSystems(ES)&Electronics
DesignTechnology(EDT)2017

Yourregistrationhasbeencompletedsuccessfully,yourApplicationNumberisMTech201788.
PleaseprintthispageandsendtotheaddressgivenbelowalongwithallenclosuresandDD.
DD amount is Rs 1000 for General and Rs 500 for SC/ST candidates drawn in favor of Director, AffixYour
NIELIT,CalicutpayableatStateBankofIndia,CalicutNITbranch(BranchCode2207). PhotoHere
DDNoanddatehavetobementionedcompulsorilyintheprintoutoftheapplication.
Superscribetheenvelope"ApplicationforMTechcourses2017".

Print

ApplicationNumber :MTech201788

PersonalInformation

FullNameincapital(asinDegreecertificate) :ADARSHK

Expansionofinitials :KAPIYATH
Age :22

DateofBirth :09/08/1994

AddressforComunication :ATHIRANIVASPAZHICHYILPILATHARA(P.O)KANNURKERALA

PinCode :670504

Phone :04972800978
MobilePhone :9995097079

Email :kadarsh22@gmail.com

Religion :HINDU

Caste :NAMBIAR

Category :General

PhysicallyHandicapped :No
PlaceofBirth :PAYYANNUR

District :KANNUR

StateofDomicile :KERALA

Nationality :INDIAN
MotherTongue :MALAYALAM

Father'sName :SASIDHARANPV
Mother'sName :AJITHAK

Occupationofparentorguardian :BUISNESS
RelationshipwithGuardian :SASIDHARANPV,FATHER
AnnualFamilyIncome :450000

EducationalQualifications
NameofDegree :B.Tech
Branch :ELECTRICALANDELECTRONICSENGINEERING
ModeofDegree :FullTime

Duration(inyears) :4
ResultAwaiting :No

NumberofBackPapers :0

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5/19/2017 regn.calicut.nielit.in/MTechstudentview.aspx?sid=88
NameandaddressoftheinstitutionforBSc/BCA :AMRITASCHOOLOFENGINEERINGAMRITAPURICLAPPANAKOLLAMKERALA
NameandaddressoftheUniversityforBSc/BCA :AMRITAVISHWAVIDYAPEETHAMAMRITANAGARCOMIBATORETAMILNADU

NameofExam SSLC PlusTwo BTech/BE/AMIE

AggregateMarksObtained 85.5 440 85.3

MaxMarks 100 500 100

PercentageofMarks 85.5 88 85.3

Class/Distinction DISTINCTION DISTINCTION DISTINCTION

YearofPassing 2010 2012 2016

OtherDetails
GateRegNo :EE17S51317129

GateScore :598
GateRank :3002
GateMarks :45.02

YearofPassing :2017
GatePaper :ElectricalEngineering

FirstPreference :ES

SecondPreference :EDT
AdditionalQualifications :

ProfessionalExperienceafterGraduationifany :

Employed :No

Sponsored :No
RegistrationFeeAmount :1000

DDNo :SBICOLLECT,DU66263340

DDDate :19/05/2017

Documentstobeenclosedalongwiththeapplication:

i.CopiesoftheMarkLists&DegreeCertificateoftheQualifyingExamination.
ii.CourseCompletionCertificatefromtheHeadoftheInstitutionlaststudiedandattestedcopiesofMarkListsuptotheprefinal
semester/prefinalyearforthosewhohaveappearedinthequalifyingexaminationandareawaitingresults.
iii.CopyoftheGATEScoreCard(ifapplicable).
iv.CopyofCommunityCertificateinthecaseofScheduledCaste/ScheduledTribecandidatesfromacompetentauthoritynotbelow
therankofaTahsildar.
v.CopyofCommunityandnoncreamylayerCertificateinthecaseofSEBCcandidatesfromacompetentauthoritynotbelowthe
rankofaTahsildar.
vi.CopyofNativityCertificateinthecaseofNONGATEcandidatesfromKeralaStatefromcompetentauthority.
vii.CopyofproofofDateofBirth.
viii.CopyofSponsorshipCertificateandExperienceCertificateinthecaseofSponsoredCandidates.
ix.ProofofpaymentofapplicationformfeeofRs1000forgeneralandRs500forSC/STcandidates.

Encirclethenumbersofthosewhichareenclosed

i ii iii iv v vi vii viii ix Signature

DECLARATION(Tobesignedbyallapplicants)

I .doherebysolemnlyandsincerelyaffirma)thatIhavefilledinthe
applicationformmyselfandifanystatementIhavemadeisfoundtobefalseorincorrectIshallbeliabletosuchaction
astheinstitutemaydeemproperb)thatIshallstrictlyabidebytherulesandregulationsoftheinstitutec)thatIhave
neither been involved in any criminal case nor is any case pending against me in any court of law and that I submit
myself to the disciplinary jurisdiction of the Director and other authorities of the institute. d) that I have not been
indulgedinragginginthepastandmyadmissionshallberefusedorifitisnoticedlaterthatIhaveindulgedinraggingin

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5/19/2017 regn.calicut.nielit.in/MTechstudentview.aspx?sid=88

thepastorIamindulginginraggingduringtheperiodofthefoursemesterM.Techcourseduration,Ishallbeexpelled
fromthecentreandmyadmissiongetscancelledandIhavetopayliquidateddamagesspecifiedbythecentre.
*IalsodeclarethatIhavepassedthequalifyingexaminationrecognizedbyCalicutuniversity.
*IalsodeclarethatIhaveappeared/amappearingforthequalifyingexaminationandincaseIfailtomeetthe
admissionrequirements,Ishallhavetodiscontinuetheprogramme.

SignatureofApplicant . .
Place .....

Date ./ / ..
CountersignatureofParent/Guardian
*Deletewhicheverisnotapplicable

COMMUNITYDECLARATION
(TobesignedbythosewhoseekadmissionunderSC/STquota)

I_________________________________S/o/D/o_____________________________________doherebydeclare
a)thatIbelongto CommunitywhichisanSC/STand
b)thatIundertaketoproduceatthetimeofCounselling/Admission,anoriginalcertificatefromtheRevenueAuthorities
insupportofmyclaimforcommunityreservation.

SignatureofApplicant .......................
Place ..................

CountersignatureofParent/Guardian .
Date / ../ .

ForOfficeuseOnly
CertificatesVerified Scrutinised
ReasonsforIneligibility
ProvisionallySelected
CoordinatorM.Tech Director

Addressforsendingtheapplication

TheMTechCoordinator,
NIELITCalicut,
PBNo5,NITCampusPO,
Calicut,
Kerala673601

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