GOVERNMENT OF TAMIL NADU
DEPARTMENT OF TECHNICAL EDUCATION, BOARD OF EXAMINATIONS, CHENNAI – 25
EXAMINATION APPLICATION FORM (GRACE CHANCE) APRIL 2010
Reg No

Scheme of Study
Full Time
Part Time
Sandwich
Private
Name of the Candidate

Male

HSC (A)

Branch

HSC (V)
Institution Code

Details of Last Appearance

Date of Birth

Sex

If joined in second year
(lateral entry)

Reg No

Month & Year

Female
Address for Communication

Affix Passport Size Photo
(to be attested by the
Head of the Institution)

Contact Phone /
Mobile No(s)
DETAILS OF FIRST APPEARANCE
First Year

II Semester

First Year

II Semester

III Semester

IV Semester

V Semester

VI Semester

VII Semester

VIII Semester

VII Semester

VIII Semester

Reg No

Month &
Year

Scheme
Total
No. of
Subjects

DETAILS OF YEAR / SEMESTERS COMPLETELY PASSED

Reg No

Month &
Year

III Semester

IV Semester

V Semester

VI Semester

MARKS SCORED IN SUBJECTS ALREADY PASSED

(fill up the details only for passed subjects, enclose attested copy of mark certificates with marks)
Col No

First Year
IM

EM

III Semester
Total

IM

Total

IM

EM

IV Semester
Total

IM

Total

IM

EM

V Semester
Total

IM

EM

Total

Total

IM

EM

Total

1

2

3

4

5

6

7

8

9

10

11
Col No

1

2

3

4

5

6

7

8

VI Semester
IM

EM

VII Semester
EM

VIII Semester
EM

DETAILS OF ARREAR SUBJECTS
As per Scheme of Study
Year /
Semester

Col No

Name of the Subject

As per “J” Scheme Equivalence
Year /
Semester

Col No

Name of the Subject

Internal
Marks
Secured

I hereby declare that
• The information furnished in this application is true, correct and complete.
• I am appearing for all failed subjects.
• I will be awarded Dipoma only on application with proof of passing all subjects (with marks).
• I am fully aware that this is a special scheme announced by the Government for writing the examination to the candidates (who
have exhausted their chances) to complete the Diploma in three attempts (January 2009, October 2009 and April 2010)
• I will not claim any more chances for writing the Examination in future.
• I am aware that incomplete applications & applications without proper enclosures will be summarily rejected.

Countersigned

Signature of the Head of the Institution with Seal

Signature of the Student with Date