STATE BOARD OF TECHNICAL EUCATION & TRAINING, A.P., HYDERABAD.APPLICATION FORM FOR POLYCET-2015

(For State of Andhra Pradesh)

10th Class Hallticket No.

Year of Passing

Date of Birth

a. Read the instructions given on the back side of the form.b. Use Code only for item No. 4, 6, 7 & 9 as shown in the back page

01. Name (In Block Letters as per SSC)

02. Father's Name

03. Date of Birth 04. Sex

05. Address for Correspondence

House No.

Village / Street

Mandal / Town / City

District

PIN

Mobile Number 05 (a): Town in which you would like to appear for examination

06. Local / Region 07. Reservation Category

08. Special Category NCC SP PH CAP

09. Minority Community 10. Willing to have assistance in Urdu Medium

11. I delcare that I fulfill the eligibility criteria laid down for appearing at POLYCET-2015 and I shall submit all the originaldocuments in proof at the time of admission into Polytechnics for the acdemic year 2015-16. I also certify that I am notsuffering from any of the following defects, (a) Mentally Rtarfed (b) Deaf & Dumb (d) Deaf & Dumb (d) Chronic Heart, Lung,Kidney, Liver Diseases (e) Muscular Dystrophy. The information furnished above is true to the best of my knowledge andbelief. In case any false information is furnished by me, I shall be made ineligible for admission and I will have no right to claim.

Signature of the Parent / Guardian Signature of the Candidate

Paste thePassport size

Photograph in this box

Do not Staple/pinDo not sign on the

Photograph

BoardSSC/CBSE/ICSE/NIOS/APOSS

D D M M Y Y Y Y

Item No. Item Description Code Expansion

04. Sex M male

F Female

06. Local/Region AU Andhra University Area

OU Osmania University Area

SVU SV University Area

NL Non-Local

07 Reservation Category BCA Back-ward Class - 'A' Group

BCB Back-ward Class - 'B' Group

BCC Back-ward Class - 'C' Group

BCD Back-ward Class - 'D' Group

BCE Back-ward Class - 'E' Group

SC Scheduled Caste

ST Scheduled Tribe

08. Special Category If eligible place a tick mark ()in the respective boxes

09. Minority Community Christian

Muslim

Parsi

Sikh

Buddhist

Anglo Indian

Any Other

10. Willing to have assitance in Y Yes

Urdu Medium N No

Instruction for filing up of Application Form for Computerization purpose

1. Application form should be filled properly and legibly by the student in his/her own handwriting with ball pen, (blue or black) in CAPITAL LETTERS only.

2. Only good quality Passport size photograph should be pasted. Please do not staple or pinthe photograph. Please do not sign onthe photograph

3. Only codes should be entereed inthe boxes provided against items 4, 6, 7, & 9 in the Appli-cation Form.

4. Student has to choose the town/city in which he would like to appear for examination.

5. APOSS/NIOS shall cover Mathematics, Science, Social/Computers and should be passedin all subjects with a minimum of 35% in each subject.