SRI SATHYA SAI INSTITUTE OF HIGHER LEARNING

(Deemed to be University)

Vidyagiri, Prasanthinilayam - 515 134,

Anantapur District, Andhra Pradesh
Website: www.sssihl.edu.in Email: registrar@sssihl.edu.in

APPLICATION FOR ADMISSION TO UNDERGRADUATE PROGRAMME

BACHELOR OF SCIENCE (HONOURS) - MPC [MATHEMATICS, PHYSICS, CHEMISTRY]

LAST DATE FOR SUBMISSION: March 10, 2019

If you are applying for more than one course, please mention the Applicant ID and the course.

Applied for: Applicant ID(s).: ______________________ Programme(s): ______________________

Applicant ID: 1920-07511

1. Applicant Name: R ANUSHA

2. Gender: FEMALE
Please affix
(do not pin)
3. Date of Birth: 30-06-2001 (17 yrs) your recent
Passport size Photograph

4. Place of Birth: THANJAVUR

5. Country of Birth: INDIA

6. Place of Residence: CHENNAI

7. Nationality: INDIA

8. Permanent Address: 4/18,SECOND STREET

BALAJI NAGAR
NANGANALLUR

CHENNAI

State: TAMIL NADU

Pincode: 600061

Country: INDIA

Mobile: 9444955429 Landline: 04448592253

9. Mailing Address: 4/18,SECOND STREET

BALAJI NAGAR

NANGANALLUR

CHENNAI

State: TAMIL NADU

Pincode: 600061

Country: INDIA

Mobile: 9444955429 Landline: 04448592253

Email ID: rajshiam1166@gmail.com

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10. Name of Father / Guardian: Father: RAJAGOPALAN S

11. Occupation: GOVERNMENT SERVICE

12. Annual Income: 10,00,000

13. Mother's Name: SHIAMALA N

14. Occupation: HOUSE WIFE / HOME MAKER

15. Annual Income: 5000

16. Mother Tongue: TAMIL

17. Religion: HINDU

18. Community: Others

SECONDARY SCHOOL LEVEL - X Std

19. Name of the School: MODERN SENIOR SEC SCHOOL

20. Place where the school is located: NANGANALLUR,CHENNAI

21. Medium of Instruction: ENGLISH

22. Board to which the school is affiliated: CBSE

23. Year of Passing: 2017

24. Statement of marks: Marks Obtained Out Of Gen. Eng. %

1. GENERAL ENGLISH 9.00 10 90.00

2. TAMIL 9.00 10
3. MATHAMATICS 9.00 10

4. SCIENCE 9.00 10

5. SOCIAL SCIENCE 9.00 10

6. INFO TECHNPLOGY(C) 9.00 10 Aggregate %

TOTAL: 54.00 60 90.00

(Enclose attested photocopies of statement of marks) (All subjects including
English & Language)

HIGHER SECONDARY SCHOOL LEVEL - XII Std

25. Name of the School:

26. Place where the school is located:

27. Medium of Instruction:

28. Board to which the school is affiliated:

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29. Year of first appearance and subject combination
for the XII Std. Board Examination:

30. UG Course for which admission is sought: BACHELOR OF SCIENCE (HONOURS)

31. The subject combination in which the candidate MATHEMATICS, PHYSICS,

PHYSICS CHEMISTRY
would like to take the Admission Test:

32. Statement of marks in the XI and XII Std Board Examination:

XI Std. Marks Obtained Out Of XII Std. Marks Obtained Out Of

GENERAL ENGLISH 89.00 100

TAMIL 65.00 100

MATHEMATICS 45.00 100

PHYSICS 50.00 100

CHEMISTRY 52.00 100

COMPUTER SCIENCE 62.00 100

TOTAL 363.00 600 TOTAL

GENERAL ENGLISH % 89.00 GENERAL ENGLISH %

AGGREGATE % 60.50 AGGREGATE %

(Enclose attested photocopies of statement of marks)

33. Did you passed XII Std in first attempt? If not, mention the number of attempts made for Supplementary
Examination and subject(s) failed.
YES No. of Attempts:
Subject 1:

Subject 2:

Subject 3:

34. Have you applied for admission to this Institute before? If so, furnish the particulars below:

Course: Year when Admission was sought:

1.

2.

3.

35. Have you now applied elsewhere for admission? If so, furnish the particulars below:

Course: University / College Date of Admission Test

1.

2.

3.

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 ADDITIONAL PARTICULARS
36. Extra curricular activities:

Indicate below with a tick mark, the extra curricular activities you have participated in:

N.C.C Photography Games Painting/Drawing

Yoga Music - Vocal a Debates Dramatics

Dance Music - Instrumental

37. Mention your achievements, if any, and the awards or honours received:

38. Have you ever been a member of any Sri Sathya Sai Organisation? If so, give particulars:

Bal Vikas: From: 2009 To: 2018

Pre-Sevadal: From: To:

EHV Programme: From: To:

Sevadal: From: To:

39. Furnish below the particulars about your parent(s), own brother(s) and/or sister(s) who have studied /
who are studying in any of the campuses of the Sri Sathya Sai Institute of Higher Learning or Sri Sathya
Higher Secondary School, Prasanthi Nilayam.
S. No. Name Course / Standard Total year(s)
of study
1.

2.

3.

DECLARATION BY THE APPLICANT

I hereby declare that all the particulars given above by me are true to the best of my knowledge.

I further declare that I have read the Information Handbook, Admission Handbook provided, and that if I am admitted, I shall abide
by all the terms and conditions stated therein.

I assure that if I apply to any other Institution/University after preferring this application, I shall inform the same to the Interview
Board of the Institute at the time of the Interview.

I undertake not to apply for any other course, after joining the Institute, without the prior permission of the Head of the Campus of
the Institute.

Place:

Date: Signature of the Applicant

DECLARATION BY PARENT / GUARDIAN

I hereby certify that the information provided above is correct, and I bear the responsibility of withdrawing my son/daughter/ward
from the course after admission, if any of the information given above is found to be wrong.

Place:

Date: Signature of the Father / Mother / Guardian

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 SRI SATHYA SAI INSTITUTE OF HIGHER LEARNING
(Deemed to be University)

Vidyagiri, Prasanthinilayam - 515 134,

Anantapur District, Andhra Pradesh
Website: www.sssihl.edu.in Email: registrar@sssihl.edu.in

NOTE: The duly filled-in request form, and the respective course Application Form should be sent to the office of
Registrar, along with (i) DD or IPO drawn in favour of "Sri Sathya Sai Institute of Higher Learning", payable at
Prasanthi Nilayam or (ii) Bank Challan for Rs. 100/-, or (iii) e-Receipt of online payment via State Bank Collect,
so as to reach the Institute by 10-03-2019 for scrutiny and approval.

Course applied for: BSCH [BACHELOR OF SCIENCE (HONOURS)]

MPC [MATHEMATICS, PHYSICS, CHEMISTRY]

Name: R ANUSHA

Address: 4/18,SECOND STREET

BALAJI NAGAR

NANGANALLUR

CHENNAI

State: TAMIL NADU

Pincode: 600061

Country: INDIA

Telephone No.: 04448592253

Mobile No.: 9444955429

Email ID: rajshiam1166@gmail.com

SBCollect Reference No.: DUA4989716

Signature of the Applicant

FOR OFFICE USE ONLY

Allotted Applicant ID: 1920-07511

Applied for: BSCH [BACHELOR OF SCIENCE (HONOURS)]

MPC[MATHEMATICS, PHYSICS, CHEMISTRY]

As per the minimum requirements stated in the Advertisement, your Application form is Accepted / Rejected.

Checked by:

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 ONLINE APPLICATION FORM OF SRI SATHYA SAI INSTITUTE OF HIGHER LEARNING

Checklist before posting the duly filled-in application form!

NOTE: Any application form which is found incomplete will be summarily rejected.

Recent passport size photograph pasted in the place shown. (Please do not pin the photograph).

Enclosed the self-attested photocopies of the mark statement of all the qualifying school / degree certificates
(including supplementary examinations).

Enclosed the SBI challan / Demand Draft / IPO / e-Receipt with all details duly filled-in.

Enclosed one additional photograph indicating my name and Applicant ID on the backside.

I have validated the printed application form and updated partially shown information (if any) by hand and put my
signature against it.

Application form is duly signed and dated by both the candidate and the parent / guardian.

I certify that I fulfill the minimum requirement of marks as prescribed in the admission handbook.

Applicants for Post Graduate and Professional programmes:

I have checked and confirmed that the last date of the examination(s) of the qualifying degree in my colleges /
university IS BEFORE the Admission Test date of the Sri Sathya Sai Institute of Higher Learning.

Place:

Date: Signature of the Applicant