CMC/F.

12
Roll No: Application No:

GE
CO
IM L E
BA OL
TO
RE MARINE C

COIMBATORE MARINE COLLEGE

(D.G.Shipping, Govt. of India Approved)
296, Pollachi Main Road, Myleripalayam, Coimbatore - 641 032.
Phone : 0422 – 2611123,2611034 Fax : 2611222
e-mail : info@coimbatoremarinecollege.com
URL: www.coimbatoremarinecollege.com

APPLICATION FORM Affix here a

recent passport
B.E Marine Engineering (4Years) size photograph
of the applicant
B.Sc Nautical Science (3Years)

Tick whichever is applicable.

1. Name of the Applicant(in capital letters)

Surname
Given Name

Date of Birth : ____/____/_______ Sex : M / F Blood Group : _______________

Place of Birth : _________________________ Nationality : ________________

Identification Mark : 1. ______________________________________________________

: 2. ______________________________________________________

Colour of Eye :_________________ Colour of Hair: ________________Height : ___________

Father’s Name : ________________________________Occupation : _____________________

Mother’s Name : ________________________________ Occupation : _____________________

Annual Income : ______________________

Permanent Address
House No. / Street Name ______________________________________________________________

Village / Post Office _______________________________ District.________________________

Tehsil / State _________________________________ PIN Code. ___________________

Phone No.
With STD Code __________________________________ Email ______________________
Next of Kin : ___________________________________ Relationship :_________________________
Postal Address
House No. / Street Name ______________________________________________________________

Village / Post Office _______________________________ District.________________________

Tehsil / State _________________________________ PIN Code. ___________________

Phone No.
With STD Code __________________________________ Email ______________________

Educational Details

Educational Qualification : ________________________________________________________

Name of the School : ________________________________________________________

Name of the Board : ________________________________________________________

% of Marks in
% of Marks in PCM
English % of PCM % of 10+2
10th 10+2 Phy Che Maths

Documents to be enclosed

1. 10th Mark Sheet (06 copies attested),

2. 10+2 Transfer Certificate & Mark Sheet (06 copies attested)
3. Age proof if applicable (06 copies attested),
4. 20 Passport Size & 4 stamp size Photos (white shirt).
5. All the Original Certificate to be submitted

Details of Relations Working in Shipping / Port Trust if any:

Name : ____________________________________________________

Relationship : _____________________________________________________

Address of the Company / Port Trust: _____________________________________________________

Please indicate reasons for choosing the above indicated course

___________________________________________________________________________________

___________________________________________________________________________________

How did you come to know about CMC ? (Please indicate reference if any)

___________________________________________________________________________________

___________________________________________________________________________________

How do you propose to arrange funds to pay the fees ?

___________________________________________________________________________________

___________________________________________________________________________________

Are you aware that fees paid will not be refunded ?

Yes No

DECLARATION:

I hereby declare, to best of my knowledge that the information given above is true. I am aware of the
personal safety aspects while training and that I do not suffer from any illness or disability that may
hamper the various physical exercises to be carried out during the courses as part of its training the
course period. Coimbatore Marine College or any other organization involved in the training will not
be held responsible in any way, for any accident or injury suffered by me during this course.

I also agree to sign the standard Agreement with the Institution. I agree to abide by the campus and
Hostel Rules.

Place:

Date : Signature of Applicant Signature of Parent / Guardian

[* Legal – Legal Disputes if any is Subject to Coimbatore jurisdiction only]

 FOR OFFICE USE ONLY

Application Issued on : ___________________ Application Received on : ___________________

Medical Form No : ___________________

Eligibility

Marks Obtained English Mark Age (as on date)

Phy : ________ 10+2 : ________ D.O.B : _______________
th
Che : ________ 10 : ________ Age : _______________
Mat : ________
PCM : ________%

Medical Test Report

EYE Sight : Normal Others Specify __________________________

Colorblindness : Yes No

Documents Enclosed Xerox (06 copies) Original

1. 10th Mark Sheet

2. 10+2 Mark Sheet

3. 10+2 Transfer Certificate

4. Age proof if applicable

5. 20 Passport Size & 4 stamp size Photos (white shirt).

Signature of the counselor

Remarks:

Date : Director