PERMISSION - CUM - ADMISSION FORM FOR

STATE BOARD OF TECHNICAL EDUCATION,

HARYANA
(ALL ENTRIES TO BE FILLED UP IN BLOCK LETTERS
ONLY)

1. EXAMINATION (MONTH/YEAR)
2. ROLL NO.
PASTE YOUR
3. NAME OF THE DISCIPLINE PHOTOGRAPH
AND GET IT
4. NAME OF THE CANDIDATE
(as per matric certificate) ATTESTED
FROM THE
5. FATHER'S NAME
DEPARTMENT
(as per matric certificate)
6. MOTHER'S NAME
(as per matric certificate)
7. INSTITUTION : SETH JAI PARKASH POLYTECHNIC, DAMLA

8. ADDRESS :
A) PERMANENT / CORRESPONDENCE B) PRESENT / CORRESPONDENCE

SETH JAI PARKASH

POLYTECHNIC, DAMLA
MOBILE NO.
YAMUNA NAGAR - 13 5001
9. SUBJECT IN WHICH CANDIDATE WISHES TO APPEAR (Give Subject Codes only)
Sr. No. I SEM. II SEM. III SEM. IV SEM. V SEM. VI SEM.

1.

2.

3.

4.

5.

6.

7.

Month & Year

Last appeared

I Solemnly declare that I have not been debarred on account of detention in session/attendance/U.M.C./Conduct/not depositing of fee/
having already availed max. permissible changes/duration for the examination to be held in (month/year)

Date Signature of the Candidate

CERTIFICATE BY THE PRINCIPAL

1. Certified that is/was bonafide student of this institute.
2. Certified that particulars given above by the candidate are correct as per official record.
3. Certified that Roll no. slip has been issued to the candidate after ascertaining his eligibility in all respects to sit in the examination.
4. Certified that the conduct of the candidate is .

Date Signature Signature of Principal

O/I Exam. and seal of Institute