GOVERNMENT OF TAMIL NADU

DIRECTORATE OF TECHNICAL EDUCATION

TAMIL NADU ENGINEERING ADMISSIONS - 2024
Application for Admission to B.E/B.Tech Degree Course
Application Number: 248616

Personal Information
Name: MOHAMMED OSAMA YUSOUF S M Name of the Parent/Guardian: MOHAMED ZULFIKAR ALI HUSSAIN S M
Communication Address: Permanent Address:
Old No. 74, New No. 171, Portuguese Church Street, Sevenwells, Chennai - 600001 Old No. 74, New No. 171, Portuguese Church Street, Sevenwells, Chennai - 600001
State: Tamil nadu District: Chennai
Taluk: Tondiarpet Communication address pincode: 600001
Native District: Chennai Civic status of Native Place: Municipality
Date of Birth (DD-MM-YYYY): 15-04-2006 Gender: Male
Mother Tongue: Tamil Nationality: Indian
Nativity: Tamil nadu Religion: Muslim
Name of the Community: BCM Name of the Caste:
Labbais including Rowthar and Marakayar (whether their spoken language is Tamil or Urdu)
Aadhar Number (optional): 821098156446

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:
Government Polytechnic College Purasawalkkam Chennai-600 012

Scholarship Information
Parent Occupation: Business Annual Income: 600000
Are you a First Graduate?: No Post Matric Scholarship (SC/SCA/ST/Converted Christians): No
Are you planning to avail education loan?: N

School of Study Information

Category of School: Govt. Aided Civic status of school location (+2): Municipality
Have you studied VIII to XII in Tamil Nadu?: Yes Have you studied from VI to VIII in private school under RTE and IX to XII
in Government School?:
No
Have you studied VI to XII in Government school?: No

Class Year of Passing Name of the school District State Block Category of
Govt.School

VI Std. 2018 Bishop Corrie Ai Hss Chennai Tamil nadu Royapuram --

VII Std. 2019 Bishop Corrie Ai Hss Chennai Tamil nadu Royapuram --

VIII Std. 2020 Bishop Corrie Ai Hss Chennai Tamil nadu Royapuram --

IX Std. 2021 Bishop Corrie Ai Hss Chennai Tamil nadu Royapuram --

X Std. 2022 Bishop Corrie Ai Hss Chennai Tamil nadu Royapuram --

XI Std. 2023 St Marys Mat Hss Chennai Tamil nadu Royapuram --

XII Std. 2024 St Marys Mat Hss Chennai Tamil nadu Royapuram --

Academic Information
Qualifying Examination: TN-HSC Name of the Board of Examination: Tamil nadu Board of Higher Secondary Education
Permanent register number: -- HSC Roll number: 6744362
Qualified Year: 2024 HSC Group: HSC Academic
Group Code: Physics/ Chemistry/ Maths/ Computer Science Medium of Instruction: English
HSC maximum (total) marks: -- HSC obtained marks: --
SSLC maximum (total) marks: 500 SSLC obtained marks: 454
Have you applied for NEET ?: No Have you applied for JEE ?: Yes
Have you applied for Indian Maritime University Common Entrance Test (IMU Educational Management Information System(EMIS) Number: 1016145737
CET)?:
No
Community certificate number: TN-5201912261587 Nativity certificate number (if applicable): --
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSIONS - 2024
Application for Admission to B.E/B.Tech Degree Course
Application Number: 248616
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSIONS - 2024
Application for Admission to B.E/B.Tech Degree Course
Application Number: 248616

Affix recent Passport

size Photo

DECLARATION BY THE APPLICANT

I, MOHAMMED OSAMA YUSOUF S M (Son / Daughter) of MOHAMED ZULFIKAR ALI HUSSAIN S M 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, MOHAMED ZULFIKAR ALI HUSSAIN S M (Parent / Guardian) of MOHAMMED OSAMA YUSOUF S 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 ADMISSIONS - 2024
Application for Admission to B.E/B.Tech Degree Course
Application Number: 248616

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 BCM (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