Roll Number

Public College, Samana (Patiala)/

Public Collegiate Sr. Sec. School, Samana/

Public College of Education, Samana

Registration Form

Session: 2021-2022

Class in which Admission is Sought*

Year*

Select Semester*

Upload Photo*

1. Name of the Applicant*

2. Father's Name*

3. Mother's Name*

4. Student Email*

5. Mobile*

5-a. Whatsapp No.*

6. Phone

7. Date of Birth*

8. Gender*

Male
Female

9. Student's Aadhar No.:

10. Permanent Home Address*

11. Correspondence Address

Same as Permanent Home Address

12. Select applicable fields and attach the certificates for Reserve Category

Resident Area*

Rural Resident
Urban Resident

Caste Category.*

General
S.C
S.T
O.B.C
Handicapped
Riot Victim
Freedom Fighter
Defence Personnel

Medium*

Punjabi
Hindi
English

Religion

Choose If applicable

Sport Person
Hosteller

13. Have you passed 10th or 10+2 Examinations from Rural Area?*

Yes
No

14. If you belong to SC/ST/OBC Category, then attach Caste Proof

Format jpg, gif, png, pdf, jpeg max size 1 mb

15. Occupation of Father/Mother/Guardian*

16. Annual Income*

17. Educational Qualifications

Exam Passed	School/College	Year	Roll No.	Univ./Board	Marks Obtd.	Total Marks	%age

17 (a). Attach Matric / 10+2 / Graduation Certificate

Format jpg, gif, png, pdf, jpeg max size 1 mb

18. a) Name of the Institute & District from where passed the qualifying examination

b) Roll no. of Previous Class

if student of Public College/Public Collegiate Sr. Sec. School

Enter Subjects only for Humanities (Arts) Classes*

Subject Combinations for B.A. First Year Only

Candidates must fill all the three subjects strictly selecting one from first column and remaining two from column opposite to the first column (corresponding column)

Group	First Subject	Any two subjects from the corresponding subjects
A	Mathematics	Computer Application/Economics/Political Science/Geography/ Any one Literature (Punjabi or Hindi or English)
B	Computer Application	Mathematics/Economics/Psychology/Public Administration/ Any one Literature (Punjabi or Hindi or English)
C	Economics	Mathematics/Political Science/Computer Application/ History/ Religion/Home Science/ Any one Literature (Punjabi or Hindi or English)
D	History	Geography/ Economics/ Political Science/ Public Administration/ Home Science/ Physical Education/ Music Vocal/ Any one Literature (Punjabi or Hindi or English)
E	Geography	Political Science/ Mathematics/ Economics/ History/ Public Administration/ Religion/ Any one Literature (Punjabi or Hindi or English)
F	Political Science	Mathematics/History/Economics/Home Science/Geography/ Music Vocal/Psychology/Physical Education/ Religion/ Any one Literature (Punjabi or Hindi or English)

* Mathematics subject will be offered only to students who have studied it in 10+2

19. Subject - I

20. Subject - II

21. Enter First Optional Subjects

22. Enter Second Optional Subjects

23. Enter Third Optional Subjects

24. Mode of coming to College

Cycle
Scooter
Moter Cycle
On Foot

Declaration:*

I hereby declare that I have taken admission in this College/School with the permission of my parents. I am also giving it in writing that I will remain/maintain discipline during my stay in this institution and if found guilty or face suspension will abide by the decision taken by the Principal. I have read all the rules and regulations as written in the syllabus book of the University/Board and I will fulfil all the conditions. If, I don’t fulfil all desired criterion, I may not be issued the University/Board Roll number for the exams. The information given in the aforementioned form is true to my knowledge.
I declare that the information given in the form regarding my postal address is absolutely correct. I will remain in touch with college authorities and will keep a check on the attendance and house exam record of my ward. If my ward doesn’t fulfil any of the conditions according to the given rules, then I will agree/abide by the decision taken by the college/school committee.

For any query please contact 8968700879/ 8146546906

Parent's Signature

Candidate Signature

Admission Committee

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