- Ethiraj College

ETHIRAJ COLLEGE FOR WOMEN (AUTONOMOUS)
SS
# 70, Ethiraj Salai, Chennai - 600 008
AFFILIATED TO THE UNIVERSITY OF MADRAS
APPLICATION FOR ADMISSION 2015-2016 B.A. / B.Sc., / B.Com. / B.B.A. / B.C.A.
Application No.
APPLICATION FORM TO BE FILLED IN BLOCK LETTERS
ENTER COURSE CODE YOU ARE APPLYING FOR
(REFER INSTRUCTIONS AT THE BACK)
1. Name of the Student as per the School Transfer Certificate
2. Parent’s Name / Guardian’s Name
2(A) Relationship
F - Father
M - Mother
G - Guardian
2(B) Occupation
2(C) Gross Annual Income of the Family
S - Self
G - Govt.
P - Private
3. Date of Birth (DD / MM / YYYY)
4. Community Code
OC
BC
BCM (BC Mulsim)
MBC
7. Are you of Tamil Origin from the
6. Nationality
Andaman and Nicobar Islands?
INDIAN
Yes / No
NRI
OTHERS
12. Distinction in Extra Curricular
Activities / Co-Curricular Activities
State Level
National Level
International Level
5. Caste as per School & Community Certificate
DNC
SC
SCA (Arundatiyar)
ST
8. Are you a first
generation learner?
Yes / No
13. Are you a daughter of
an Ex-Service man?
Yes / No
9. Distinction in Sports
A1-District
B2-State
C3-National
D4-International
14. Are you Differently - Abled?
Yes / No
17. Address for Communication (Please do not write your name again)
10. NCC
Yes / No
11. NSS
Yes / No
15. Are you from Rural Area?
Yes / No
16. Do you want to be considered for Admission under NRI Quota?
Yes / No
City
Pincode
State
Landline Number
Mobile Number
Email ID
18. NAME AND LOCATION (DISTRICT) OF SCHOOL LAST ATTENDED
19. Board of Qualifying Examination Passed
Tamil Nadu State Board
Central Board
Others
20. Medium of Study at +2 level
Tamil
English
Others
Subject Code
(Refer Instructions at the back)
22. Statement of Marks
Month
21. Register Number
Year of
Marks / Grade
Appearance obtained
Maximum
Marks
No. of
Attempts
LANGUAGE
ENGLISH
SUBJECTS
PLACE :
DATE :
DECLARATION
SIGNATURE OF THE APPLICANT
I declare that all the particulars furnished above are true and correct.
I submit that I will abide by the rules and regulations of the college.
SIGNATURE OF PARENT / GUARDIAN
Note : 1. Incomplete / Incorrect applications will be rejected. 2. There should not be any overwriting.
FOR OFFICE USE ONLY
SIGNATURE OF STAFF WHO PROCESSED THE APPLICATION ...............................
SIGNATURE OF HEAD OF THE DEPARTMENT ...........................................................
PRINCIPAL ...................................................
ADMISSION No. ...........................................