S.N.MUDBIDRI POLYTECHNIC,
MOODBIDRI, POST KODANGALLU, MANGALORE TQ - 574194, D.K
(MANAGED BY S.M.C Trust, Moodbidri & The Academy of General Education, Manipal)
Recognised by AICTE, New Delhi & Affiliated to B. T. E. Bangalore
E-mail : principal@snmpolytechnic.org
Fax : 08258 - 239663

Website : www.snmpolytechnic.org
Phone : (08258) - 236663

APPLICATION FOR ADMISSION TO THE FIRST YEAR DIPLOMA COURSE IN

...........................   ENGG. FOR THE YEAR  ................   - ...............

( To be filled by the cadidate in block letters only )

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1. Name of the candidate (in full)
(As in S.S.L.C / equivalent certificate)
2. a) Father's Name (As in S.S.L.C / equivalent certificate)
  b) Mother's Name
  c) Gardian (In the event of death of parents)
3. Permanent/local address of the candidate, with pincode
    Phone No. with STD code compulsory)
    Mobile +91-
4. a) Date of Birth  /   / 
  b) Age (Completed years)
5. Sex Male / Female
6. Mother Tongue
7. Native District & State
8. Religion
9. Cast/Category SC / ST / Category-1 / 11A / 11B / 111A / 111B/ GM / Rural / Urban / Non- Karnataka candidate
10. a) Name & Place of the school/college last studied
  b) No. of full academic years of study in karnataka state (between 1 to X std.)
  c) Mention Whether Rural/Urban
11. a) Occupation of the Parent/Gardian
  b) Annual income of Parent/Gardian : Rs
12. Detail of S.S.L.C or Equivalent Examination :
 
Qualifying Examination Name of the board Month & Year of passing Total Marks obtained Max. Marks
Marks obtained in
Maths Science Total
% of marks scored in Maths & Science
S.S.L.C. / Equivalent
13. Choice of the courses in the order of preference (put 1, 2, 3)
 
i) Electronics & Communication Engineering iv) Automobile Engineering
ii) Electrical & Electronics Engineering v) Mechanical Engineering (General)
iii) Computer Science & Engineering vi) Civil Engineering
      viii) Mechatronics Engineering
DECLARATION BY THE CANDIDATE
1. I wish to apply for S.N.M Polytechnic, Moodbidri and i declare that all the particulars stated in this application are true to the best of my knowledge & belife.
2. I hereby declare that if admitted, I agree to Conform to all the rules and regulations at present in force or that may be made hereafter by the administration of the Polytechnic and will not involve in any distructive activities. If i am involved in any such activities as well as ragging etc., I will be expelled immediately from the institution and also from the campus.
3. I understand that association whether active or passive with any unlawful organisation is forbidden.
4. I undertake that as long as I am a student of this Polytechnic, I will not indulge in any indiscipline or indulge in illigal activities like damaging and destroying Polytechinc property and if found guilty, suitable disciplinary action may be taken against me by the management.
5. I agree to abide by the attendance requirement from the date of my admission to the Polytechnic and i agree to earn the minimun required attendance, i.e. 75% in each subject before being eligible to be sent up for the Semester diploma examinations.
6. I agree to pay all the prescribed fees at the time of admission and till the complition of the course of studies, in time.
7. I am aware that my admission is subject to approval by the Directorate of Technical Education, Bangalore (Government of Karnataka) without which i will not be eligible to write the Semester diploma examinations.
8. My admission is provisional and if rejected by the Directorate of Technical Education, Bangalore for Technical reasons/for want of necessary certificates, I am liable to satisft their requirements failling which my admission will be cancelled.
Place :
Date : 		Signature of the Candidate
UNDERTAKING BY THE PARENT / LEGAL GUARDIAN
In the event of the candidate, who is my son/daughter/ward/being admitted to S.N.M. Polytechnic, Moodbidri, I hereby give an undertaking to pay regularly all his/her fees due to the institution till the complition of his/her course of studies. I also undertake to be responsible for his/her discipline and conduct.
I shall co-operate with the management to see that the descipline of the institution is maintained by my son/daughter/ward; and that he/she attends the classes with a minimum of 75% attendance, failling which the management is free to take appropriate disciplinary actions against him/her.
Place :
Date : 		Signature of the Candidate
MEDICAL FITNESS CERTIFICATE
(By registered Medical Practitioner)
I do hereby certify that i have examined Mr./Miss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a candidate for admission for I year diploma course at S.N.M. Polytechnic, Moodbidri, and that I have not discovered any disease, Constitutional affliction or bodily infirmity except. . . . . . . . . . . . . . . . . . . . . . . . . . . . . which i do not consider as a disqualification for undergoing the diploma course.
His/Her age according to his/her own statement is . . . . . . . . . . . . . . . . . . . . . . . . years and by appearance about . . . . . . . . . . . . . . . . . . . . . . . . years.
His/Her blood group is. . . . . . . . . . . . . . . . . . . . . . . .
Place :
Date : 		Signature of the Candidate
TO BE FILLED BY THE POLYTECHNIC OFFICE
1. The candidate has been provisionally admitted/not admitted, to 1 year diploma in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engineering.
2. Region of the candidate: Hindu/Muslim/Christian/Jain/Other
3. Caste/Category: SC/ST/Category - I/IIA/IIB/IIIA/IIIB/GM/Rural/Urban/Non-Karnataka Candidate
4. Date of provision admission:
Principal

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