GOVERNMENT OF KARNATAKA

DEPARTMENT OF TECHNICAL EDUCATION

APPLICATION FORM FOR ADMISSION TO INTERNATIONAL TWINNING PROGRAMS AT S J GOVT
POLYTECHNIC BENGALURU FOR THE YEAR 2021-22

To,
The Principal,

1. SATS NO. 2.Aadhar No.

3. Name of the candidate (in BLOCK LETTERS only)

4. Name of the Mother

5. Name of the Father

6. Date of Birth 7. Gender

D D M M Y Y Y Y Male Female Others

8. Indian Nationality Yes NO 9.Religion

28. PLEASE AFFIX YOUR
PASSPORT SIZE
10. Qualifying Examination 11.Code of the PHOTOGRAPH USING
SSLC CBSE
(Please Tick the appropriate box) Native State GUM. DO NOT USE
12.If Karnataka,
STAPLER OR PIN
Code of the Native
ICSE OTHERS District

13. Code of the 15.Have you studied in 16.Have you studied in

14.Total No.of Years Yes No Yes No
State appeared for rural areas from 1st to Kannada Medium from 1st
Studied in Karnataka
SSLC or equivalent 10th Std to 10th Std

17.Do you claiming Yes No 18.If Yes, Mention Clause Yes No 20.Do you claiming Yes No
19.Do you claiming
exemption from 5 code (See instruction No.3 Hyd-Kar quota
SNQ quota benefit
years of study rule of the Genral Instructions benefit

NCC JTS JOC EDP DP PS SP SG PH AI CI HK GK ITI

21.Do you claiming Special Category
benefit, (Please Tick the appropriate box)
 24.Annual income of Parent's from all
23.Name of the Caste the sources
22. Reserved Category Code
which you belongs to

25.EDUCATIONAL PARTICULARS AND MARKS DETAILS

A) Register Number of SSLC Year of

or Equivalent Exam Passing

1) Total Max. Marks in all subjects Total Marks obtained

2) Max. Marks in Science Marks obtained

3) Max. Marks in Maths Marks obtained

Total Marks
4) Total Max. Marks in Science & Maths obtained in Science
& Maths

26.Student Mobile Number:

27.Full Postal Address (in BLOCK LETTERS only)

Parents Mobile Number:

PIN CODE

E-mail ID:

28 Program at your choice: Priority Number Program Name

Travel & Tourism
Cyber Physical Systems & Security
We decalre that the above information is true andDECLARATION
correct to the best our knowledge and belief. In case if any of the
above information is found to be false or incorrect, we shall forfeit the claim to be considered for a seat in a
polytechnic. In such an event, we will also be liable for civil and criminal action as the Government or the Department
of Technical Education may take action against us in this behalf. Also we abide by the rules existing at the time of seat
selection process.

Signature of the Candidate Signature of the Parent/Gardian

Date: Date: