Application No:
LITTLE FLOWER INSTITUTE OF SOCIAL SCIENCES AND HEALTH (LISSAH)
(Affiliated to the University of Calicut)
Kaithapoyil P O, Kozhikode – 673 586, Kerala, India
Tel. No. 0495-2232085, 2234129, 2232164
www.lissah.com
APPLICATION FOR ADMISSION TO UG Courses 20 __ 20__
BSW
Affix passport
size photo
B. Sc Psychology
B.Com Finance
B. Sc Computer Science
B. Sc Statistics
BA English with Journalism & Electronic Media
Course Chosen:
I Choice
SSLC Mark/Grade:
II Choice
%
III
III Choice
Qualifying Exam/ +2 Marks/Grade:
Second Language option
:
Malayalam
1. Name of the candidate in BLOCK LETTERS
(As in SSLC Book)
2. Nationality
:
4. Gender
5. Blood Group
6. Age and date of birth(As in the SSLC Book)
:
7. Religion:
8. Community
9. Caste:
10. Category
Hindi
3. Place of Birth:
11. Permanent Home Address :
:
SC/ ST/ OBC/ OEC/ General
Present Address
Landline No :
Mobile No :
12. Name of Father/ Guardian
:
13. Occupation of Parents/ Guardian
14. Annual Income of the Parent /Guardian
15. Full Address of the institution last studied
(With Course, Group, Board and State)
Landline No :
Mobile No :
:
:
:
Name of Mother:
16. Number of chances in passing the qualifying Examination :
Year of passing:
Reg. No:
%
TC .No:
FOR OFFICE USE ONLY
17. Statement of marks of qualifying examination
(Enclose attested true copy of Mark list)
Subject
Secured Maximum Grade
Choice
I
II
III
Remark
Course
Total Marks
Subject Marks
Ex-service man
NCC/NSS
Grand Total
Deductions
No of chances
Grand Mark
General Merit- Rank
Community
Reservation
Management
18. Distinction in Sports and Games/NCC/NSS if any, :
(Enclose attested true copies of testimonials)
19. Whether Applicant’s father is an Ex-serviceman :
(Enclose attested true copies of testimonials)
20. Hostel Accommodation is required
: Yes / No
DECLARATION
I do hereby certify that the details furnished above are correct and that I shall abide by the rules of
the college and I will not involve myself in any activities against the discipline of the College and the
University.
Name of the applicant:
Signature:
Counter signed
Name & Signature of Parent/Guardian
Place:
Date:
FOR OFFICE USE ONLY
Course to which admitted:
Admission No.
Date of Admission:
Class No.
Principal
* SC/ST/OEC candidates shall produce income Certificate and Community Certificate at the time of Interview
* Enclose Xerox copies of SSLC and Plus Two Certificates with the application form
* Please see that full and accurate information is furnished against each of the column.