FORM NO...........................................

GOVERNMENT OF JAMMU AND KASHMIR

GOVERNMENT POLYTECHNIC COLLEGE SAMBA (J &K )
Village Pangwal , Sumb Road Samba (J&K) -184121 Estd. in year 2012
Email:govtpolytechnicsamba@gmail.com Phone: 01923-219403

STUDENT ADMISSION FORM

Session 2023-24 ......................................................................................................................................................

Name of the Student: Archana Siddharth Dolas ..............................................................................................................................................................................................

Parentage: NA ...................................................................................................................................................................................................................................................

Address: Railway Quarters, Neral, Tal- Karjat, Dist- Raigad 410101

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Course: SSC .....................................................................................................................................Branch: 9/C

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Admission Notification No: 88996 .................................................................................................... ............................................................................................. .....................................................

Date of Notification: 02/02/2023 ............ ..........................................................................................................................................

Category: Open
............................................................................................................................................... Roll no: NA
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Registration No: 366945999 ......................................................................................................................................................

Date of Admission: 05/02/2024 ..............................................................................

Date of completion /Discharge: 05/02/2024 ......................................................................................

 GOVERNMENT POLYTECHNIC COLLEGE SAMBA (J & K)

Detail of Student
(To be filled by the office)

Session ......................................................................................................................................................................................................................................................................................................................................................... Affix recent

passport Size
Branch Allotted ........................................................................................................................................................................................................................................................................................................

Photograph
Roll No. Allotted .................................................................................................................................................................................................................................................................................................

Date of Admission ..........................................................................................................................................................................................................................................................................................

Admission Fee Receipt No. .........................................................................................................................................................................................................................................................................................................................................................

(To be filled by the Candidate legibly in his/her own handwriting)

1. Name ( in Capital letter )

( Strictly as per matriculation certificate ) ...........................................................................................................................................................................................................................................................................................................................................................................................................

2. Parentage ( Strictly as per matriculation certificate ) ........................................................................................................................................................................................................................................................................................................................................

3. Permanent Residential Address:- ................................................................................................................................................................................................................................................................................................................................................................................................

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4. Present Residential Address:- ...................................................................................................................................................................................................................................................................................................................................................................................................................

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5. Contact No:- ............................................................................................................................................................................................................ e-mail:- ..................................................................................................................................................................................................................................................................

6. Date of Birth (as per matriculation certificate ) .......................................................................................................................................................................................................................................... in

words ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7. Admission Notification No. ...............................................................................................................................................................................................Notification Date ..........................................................................................................................

8. Selection Notification No. ................................................................................................................................................................Selected in Category ............................................................................................................................................

9. Institute from which migrated

( In case of migration from other Institute) ....................................................................................................................................................................................................................................................................................................................................................................................................................

10. Reference of Migration order no. ............................................................................................................................................................................................................................................................................................................................................................................................................

11. Father’s Occupation .............................................................................................................................................................. Father’s Qualification ..............................................................................................................................................................................

12. Mother’s Occupation ......................................................................................................................................................Mother’s Qualification .........................................................................................................................................................................

13. Yearly Family Income ...........................................................................................................................................................................................................................................................................................................

14. Identification Mark (if any) ....................................................................................................................................................................................................................................................................................................................................................................................................................................................

15. Name of Scheme (If selected under any special scheme) ........................................................................................................................................................................................................................................................................................................................

16. Type of Disability (If selected under any special scheme) ..................................................................................................................................................................................................................................................................................................................

17. Details of Scholarships/Free ship if any received previously or applied

18. Game Played :-
 Academic Record

S.no. Examination Institution from Board/University Year of Marks %age of Grade

Passed which passed Passing Obtained marks /Div

Declaration by the Student

Certified that all the details given above are correct and true to the best of my knowledge. I
understand that if any information found to be wrong at any stage, my admission or Diploma is
liable for cancellation. I further undertake that I shall abide by all the rules and regulations of the
Institute and shall maintain discipline during the whole period of my studies .I solemnly aver that I
shall not act or indulge in any behaviour that may be constituted as ragging understanding
regulations of ragging and if found guilty I shall face punishment according to the regulations of the
ragging.

Signature / Thumb impression of the Student

Declaration by the Parents

Certified that all the details given above are correct and true to the best of my knowledge. I
understand that if any information found to be wrong at any stage, the admission or Diploma of my
ward is liable for cancellation. I further undertake that my ward shall abide by all the rules and
regulations of the Institute and he/she shall maintain discipline during the whole period of his/her
studies. I assure that he/she shall not act or indulge in any behaviour that may be constituted as
ragging understanding regulations of ragging and if found guilty shall face punishment according to
the regulations of the ragging. I further undertake that my ward shall not undergo any other regular
course during studies in the Institute.

Signature of the parent/Guardian

List of Documents to be attached with /presented at the time of submission of form:-

1. Matriculation 10th pass Marks Sheet.

2. Date of Birth Certificate.
3. Permanent Residence Certificate.
4. Category Certificate if admitted under any reserve category.
5. Provisional Certificate / School leaving certificate.
6. Valid Character certificate (not older than three months).
7. Four Recent Coloured Passport size Photographs.
8. Admit card of BOPEE
9. Three self addressed envelopes with 35 Rupee postage stamp
10. Two sets of attested photocopies of documents
11. File cover(Superior quality ) with Tag

FOR OFFICE USE

Checked details of the candidate from selection list and all documents found
complete & correct:-

Signature of Admission Clerk with name

Verified and found correct, hence admission fee may be accepted.

Verifying officer with name & Designation

Admission fee received vide receipt no. .................................................................................................................................... dated ....................................................................................................................................

Cashier /Accountant

Admission granted on the above said reports

HOD PRINCIPAL