KEAM 2017

Government of Kerala

OFFICE OF THE COMMISSIONER FOR ENTRANCE EXAMINATIONS

Housing Board Buildings, Santhi Nagar, Thiruvananthapuram - 695 001.
Phone : 0471- 2332120, E-mail : ceekinfo@cee.kerala.gov.in

Application No.
1113702
1 Name of Applicant SAFEENA NASRIN

2 Course opted Engineering,Medical 12 Centre of Examination KOZHIKKODE

3 Gender Female 13 Category Claim Muslim

4 Date of Birth 23/01/1999 14 Person with Disability No

5 Citizenship / Nativity Indian / Keralite 15 Inter-caste (Father or Mother No

belongs to SC/ST)
6 Studied Sanskrit in plus two No 16 Annual Family Income NA

7 Qualifying Examination Plus Two or Equaivalent

8 Special Reservation NA

9 Permanent Address THIRUMANGALATH,KUTTIKKATTOOR,KUTTIKKATTOOR,673008

10 Communication Address THIRUMANGALATH,KUTTIKKATTOOR,KUTTIKKATTOOR,673008

11 Mobile Number 9387052185 Phone Number Email ID safeenanasrint@gmail.com

12 Application Fee 800/- Payment Mode Online Transcation ID KEA171113702173689

DECLARATION
I hereby declare that I have download and read various Clauses in the Prospectus for Admission to Professional Degree Courses 2017 carefully and I agree to
abide by them. I also declare that all the statements made in online application are true,complete and correct to the best of my knowledge and belief and that in the event
of any information being found false or incorrect or ineligibility being, action can be taken against me by the Commissioner for Entrance Examinations.

Date: 02-02-2017 Thumb Impression of Candidate Signature of Candidate

ATTESTATION BY THE PRINCIPAL / HEAD OF INSTITUTION

where the candidate has studied / is studying
(OR)
ATTESTATION BY A GAZETTED OFFICER

I certify that the Photograph pasted on the application represents the true
identity of .....................................................................(write name of applicant)
I also certify that the photograph pasted on this application and the Affix the passport size
photo in this box. The
photograph printed on this application are same.
photo should be identical
to the photograph printed
on this application.
(Office Seal) Attesting officer should
sign over the photograph

Signature of Attesting Officer (with name and designation Seal)

Note:- The officer should sign on the lower part of the affixed photograph also.

OFFICE USE ONLY

KEAM-2017: IT Services: NIC Kerala 2 IP Address:'.202.83.57.10 Final Submission Done on:02-02-2017 20:12:36 Printed on:02-02-2017 20:15:27
Candidate Name :SAFEENA NASRIN (1113702)

CERTIFICATE TO PROVE NATIVITY FOR KERALITES

Candidate should submit ANY ONE of the following certificates:

(i) Self attested copy of Birth Certificate/SSLC/Relevant page of the Passport of candidate showing the candidate's
place of birth in Kerala.
(OR)
(ii) Self attested copy of Birth Certificate/SSLC/relevant page of the Passport of the candidate's father/mother showing
their place of birth in Kerala along with corroborative certificate to establish the relationship between the parent and
the candidate.
(OR)
(iii) Original certificate issued by the competent authority showing that the parent is an AIS officer allotted to
Kerala cadre with corroborative evidence proving the relationship between the candidate
and the parent.(Clause 6.1.(i))

(OR)

(In the absence of above certificates, obtain the following certificate from the Revenue officials to prove nativity)

CERTIFICATE OF BIRTH

(i)In case the candidate is born in Kerala

Certified that, Shri/Smt /Kum .............................................................................................................................................................

............................................................................House.................................................... Village ................................................................District

is an Applicant for the Admission to the Professional Degree Courses Kerala 2017 and he/she was born in Kerala.

(OR)

(ii)In case any of the parents are born in Kerala

Certified that, Shri/Smt /Kum ..................................................................................................................................... is an Applicant for the

Admission to the Professional Degree Courses Kerala 2017 and his/her father/mother Shri/Smt ................................................................................

.........................................................................House ........................................................................ Village .................................................... District

was born in Kerala.

Signature of Village Officer/Tahsildar/Any Competent Revenue Authority :.................................

Name and Designation: .............................................................................................................

Place :
Date :
(Office Seal) [Strike out whichever is not applicable]
KEAM-2017 : IT Services: NIC Kerala Date:02/02/2017
Name :SAFEENA NASRIN (1113702)

Note:
(1) Candidate's who appeared/are appearing for the qualifing examination should furnish the 'Course Certificate' given below as proof of subjects studied.

(2) B.Sc holders should attach self attested copies of mark lists of all parts of B.Sc Degree Examination in addition to the marklist of Higher Secondary
or equivalent examination.

(3) Candidates already passed the qualifying examination should attach the copy of their mark lists to prove academic eligibility, instead of course certificate.

COURSE CERTIFICATE
(To be issued by the Head of School/Institution where the applicant has completed or is
completing his/her studies in Standard XII or equivalent/Diploma in Engineering)
(Candidates who have passed the Plus Two/equivalent examination can attach
the self-attested copy of the mark sheet/pass certificate to prove academic eligibility)

Certified that Shri/Smt /Kum.., an applicant for the Professional Degree

Courses Kerala 2017,who is the son/daughter of Shri./Smt...
of ..
..(address)

*(a) is/was a student of Standard XII/equivalent during the year...with

subjects as * (i) PHYSICS (ii) CHEMISTRY (iii) MATHEMATICS (iv) BIOLOGY (v) ....
(vi)....and second language as....

(OR)

*(b)is/was a student of Three Year Diploma with Mathematics as one of the subjects

The date of birth of candidate as per school record is

Signature of the Head of the Institution:

Name :

Designation :

Name of Institution :

District :.........

Place :
Date : (Office Seal)
* Strike out whichever is not applicable.
Name: SAFEENA NASRIN (1113702)

NON CREAMY LAYER CERTIFICATE

[Certificate to be produced by Socially and Educationally Backward Classes (SEBC)/ Other Eligible Communities (OEC)
for admission to professional degree courses in educational institutions
under the Government of Kerala and in Aided / Unaided Self Financing Educational Institutions
other than minority institutions under Article 30 (1)]

This is to certify that Shri/Smt. ..............................................................................................................................

son/daughter of ......................................................................................... of .......................................................

Village .................................................................................................... District / Division in the State of Kerala

belongs to ......................................................................................................................................... Community

which is designated as a Socially and Educationally Backward Class (SEBC) / Other Eligible Communities (OEC)

as Serial No. .............................in KEAM Prospectus Annexure XI / X.

This is also to certify that the above Shri/Smt. ..................................................................................................

does not belong to the category of Creamy Layer in the light of the guidelines dated ....................................

and the schedule prescribed thereunder to exclude the Creamy Layer among the designated

Socially and Educationally Backward Classes (SEBCs) / Other Eligible Communities (OEC) in the State of Kerala.

Place: Signature of Revenue Officer

(Not below the Rank of Village Officer/Competent Authority)
Date:
Name:

Designation:

Office Seal
 KEAM - 2017

Dear SAFEENA NASRIN,

The following documents / Certificates should be sent to CEE office.

-- The first page of Printout of Application.

Affix a passport size (3.5 x 4.5 cm) photograph (this should be the copy of the uploaded photo), get it attested
by a government Gazetted Officer or the Head of the Institution where the candidate has last studied.
-- Self Attested copy of Date of Birth proof.
-- Proof of Nativity for Keralite
-- Original Course Certificate from where candidate has last studied
-- Original Non creamy layer Certificate from a Revenue Official not below the rank of Village Officer
-- Original Income Certificate (in e-District format)

Note:- The above documents are listed based on the information provided by the candidate at the time of filled-up application.
If any of the required proforma of certificate not obtained while printing the application, it can be downloaded from the home of application portal.

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APPLICATION FOR ADMISSION TO PROFFESSIONAL DEGREE COURSES

From To
SAFEENA NASRIN The Commissioner for Entrance Examinations
THIRUMANGALATH 5th Floor, Housing Board Buildings,
KUTTIKKATTOOR Santhi Nagar,
KUTTIKKATTOOR Thiruvananthapuram, Kerala.
Kozhikode, Kerala PIN: 695001
PIN: 673008