GCPP. 104/17 10,000 Cps. 4-6-2007. ADIDRAVIDAR WELFARE DEPARTMENT APPLICATION FOR ADMISSION INTO GOVERNMENT BOYS / GIRLS HOSTEL Affix passport size photograph duly attested by a Gazetted Officer FRESH I RENEWAL and attach 3 additional copies of the same photographs. 1. Name of the Applicant (in CAPITALS) : 2. (a) Date of Birth and Age : Date Month Year Age (Enclose attested copy of certificate) (b) Sex : Male / Female 3. (a) Father / Guardian's Name : (b) Father's Occupation : 4. (c) Annual Income of Family (Certificate : obtained from Department of Revenue and Disaster Management should be enclosed) Address for Correspondence : (With Telephone Number) Rs. 5. Permanent Address : 6. Community : Scheduled Caste : Sub Caste : .......................... Other Economically : Sub Caste : .......................... Backward Class 7. State Whether Resident of Puducherry?: Yes / No (If Yes, attach Residence and Nativity Certificate) 8. (a) Name of the School / College now : studying (b) Class / Course : ................. Year ............... (c) Distance of School / College from : ................. Kms. place of Residence 9. (a) Whether the applicant was an inmate : Yes / No of AWD's Hostel previously ? (b) If Yes, (i) Name of Hostel : (ii) Course / Class : (iii) Year of Study : (iv) Whether Promoted or : Detained 10. Furnish the details of Class / Course : Class ................. Course ................. last studied (Attested copy of Transfer Certificate obtained from Institution last studied should be enclosed) DECLARATION I hereby declare that particulars furnished above in the application are true and correct to the best of my knowledge and belief. I fully understand that in the event of any information being found false and incorrect, my application shall be liable for rejection and I am liable for expulsion from Hostel forthwith. I also declare that I will abide by the Rules and Regulations laid by the Department pertaining to hostel admission. Signature of Applicant Place : Date : Signature of Parent FORM - I (To be filled by the Head of Institution) Certified that Selvan/Selvi .................................................................................................. S/o. / D/o. ......................................................................... studying ................................ in the year ...................... is a bona fide student of this Institute. His / her character and conduct are good. The statement made by the student is found to be correct and application is recommended for admission into the hostel. The student has secured the following marks in the last Annual / Semester Examinations : Sl. No. Subjects Marks obtained in each subject Percentage of marks Result / Grade 1. 2. 3. 4. 5. 6. Total .... Signature of Principal / Head Master Place : Date : Name of the School / College with office seal FORM - II ( To be furnished by the Welfare Officer of the Hostel where the applicant stayed previously) Certified that Selvan/Selvi .................................................................................................. S/o. / D/o. ................................................................................................ was the inmate of this Hostel ..................... during the period from ....................... to ....................... His / her conduct and behaviour are good/unfair during the course of stay in the hostel. Hence, I recommend/do not recommend this application for Admission into hostel this year ........................ Signature of Welfare Officer Place : Date : Name of the Hostel with office seal CHECK LIST (For Office Use Only) 1. Birth Certificate Attested ... Yes No 2. Income Certificate obtained from Revenue Authority ... 3. Community / Residence / Nativity Certificate ... 4. Form - I forwarded by Head of Institution ... 5. Mark List of last Annual Examination ... 6. Transfer Certificate of last studied course ... 7. Distance of the hostel from place of Residence ... 8. Form - II forwarded by Welfare Officer of previous Hostel ... 9. 3 numbers of additional passport size photographs ... Application has been scrutinized : He / She is Considered for Admission. He / She is Not Considered for Admission. Siganture of Welfare Officer Yes No Yes No Yes No Yes No Yes No Yes No
