GOVERNMENT OF TAMIL NADU

DIRECTORATE OF TECHNICAL EDUCATION

TAMIL NADU ENGINEERING ADMISSION - 2021
Application Number: 205573

Personal Information
Name: RAGUL ADHITHYA M Name of the Parent/Guardian: R N MYLSAMY
Communication Address: Permanent Address:
2/31 B POONTHOTTAM 2ND STREET GANAPATHY , COIMBATORE 2/31 B POONTHOTTAM 2ND STREET GANAPATHY , COIMBATORE
PIN : 641006 PIN : 641006
State: Tamil nadu District: Coimbatore
Taluk: Coimbatore(North) Communication address pincode: 641006
Native District: Coimbatore Civic status of Native Place: Corporation
Date of Birth (DD-MM-YYYY): 10-06-2003 Gender: Male
Mother Tongue: Tamil Nationality: Indian
Nativity: Tamil nadu Religion: Hindu
Name of the Community: BC Name of the Caste:
Sadhu Chetty ( including Telugu Chetty, Twenty four Manai Telugu Chetty)
Aadhar Number (optional): 429988175163

Special Reservation Information

Whether you are a candidate under quota for Eminent Sports person as per Ex-Servicemen (Only Army/Navy/ Air force services are Eligible): No
annexure-II, item No.22 of information brochure?:
No
Differently Abled Person: No Differently Abled Type: --
TFC Center for certificate verification:
Govt. Polytechnic College for Women, Bharathiyar Road, New Siddhapudur (po), Coim-
batore District– 641 044

Scholarship Information
Parent Occupation: Business Annual Income: 4
Are you a First Graduate?: Yes Post Matric Scholarship (SC/SCA/ST/Converted Christians): No

School of Study Information

Category of School: Private Studied VIII, IX, X, XI, XII in Tamil Nadu: Yes
Civic status of school location (+2): Corporation Have you studied VI, VII, VIII, IX, X, XI, XII in Government school?: No

Class Year of Passing Name of the school District State School of study

VI Std. 2015 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

VII Std. 2016 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

VIII Std. 2017 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

IX Std. 2018 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

X Std. 2019 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

XI Std. 2020 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

XII Std. 2021 VIDHYA NIKETAN MATRIC HR Coimbatore Tamil nadu --

SEC SCHOOL

Academic Information
Qualifying Examination: HSC Name of the Board of Examination:
Tamil nadu Board of Higher Secondary Education
Permanent register number: XM19R0436315978 HSC Roll number: 3273532
Qualified Year: 2021 HSC Group: HSC Academic
Group Code: Physics/ Chemistry/ Maths/ Computer Science Medium of Instruction: English
HSC maximum (total) marks: 600 HSC obtained total marks: 512.81
SSLC maximum (total) marks: 500 SSLC obtained total marks: 396
Community certificate number: 6143537 Nativity certificate number (if applicable): --
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSION - 2021
Application Number: 205573

DECLARATION BY THE APPLICANT

I, RAGUL ADHITHYA M (Son / Daughter) of R N MYLSAMY hereby solemnly declare that the information furnished and the
statements given in the application and the enclosures are true, correct and complete. I further declare that should it be found
otherwise, I will be liable to forfeit my seat and / or removal from the rolls of the Institution at whatever stage of study I may be,
besides making me liable for criminal prosecution. I am fully aware that as per the directions of the Hon'ble Supreme Court of India
and Tamil Nadu Prohibition of Ragging Act 1997, Ragging is an offence, as is banned in the Institutions and anyone indulging in
ragging is liable to be punished such as expulsion from the Institutions and / or rigorous imprisonment up to 3 years, and / or fine
up to Rs.25,000/-

Place:

Date: ( Signature of the Applicant )

DECLARATION BY THE PARENT/ GUARDIAN

I, R N MYLSAMY (Parent / Guardian) of RAGUL ADHITHYA M hereby solemnly declare that I am fully aware of the declaration
made by the applicant, and I declare and bind myself on the same terms contained in the above declaration. The statements and
the information given are true, correct and complete. If it is found otherwise, the applicant is liable to forfeit the seat and / or removal
from the rolls of the Institution at whatever may be the stage of study, besides making me liable for criminal prosecution I am fully
aware that as per the directions of the Hon'ble Supreme Court of India and Tamil Nadu Prohibition of Ragging Act 1997,Ragging
is an offence, as is banned in the Institutions and anyone indulging in ragging is liable to be punished such as expulsion from the
Institution and / or rigorous imprisonment up to 3 years, and / or fine up to RS. 25,000/-

Place:

Date: ( Signature of Parent / Guardian )

Note: Guardian can execute the above declaration, only if both the parents are not alive.
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSION - 2021
Application Number: 205573

The following Certificates copy have to be uploaded to our system.

1. Transfer certificate
2. 10th Mark Sheet
3. 12th Mark Sheet
4. Permanent Community Certificate Card for BC (Permanent card / Electronic form / Digitally Signed E-Certificate)
5. Income Certificate of the Parent
6. Special Reservation Form for Sports and relevant certificates
7. Special Reservation Form for Ex-Serviceman and relevant certificates
8. Special Reservation Form for Blindness & Low Vision and relevant certificates