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Application for _ _ _ _ _ _ _ ___Examination, 20 _ _ ( )

rn I I I I I I I I
Admission No.: I I
1. DMU Registration No.

2. Roll No. I I I I I I w
w I I ~JD ID I IITIITII
3. COLLEGE CODE
4. Name in full
I ·1 0
I I . I I IOI I nn I IDITIJI I I
S. Father's Guardian's
Name
I I I I I I I I I DI I I nn I I I
LJLJI I I [II.TI I IITI I I I I I I
6. Permanent
I I I 1n I I I I
Address
m I Ll~] I I 01 I ltIITII I I ~]
8. Semester DITTI
1. Programme Code
DOI I I 9. Sex IM I F I O I
10. Category ~§]~§][;]~
11. Subjects/Papers to appear

Paper Code (ABC .....) Paper No. (1/2/3 .... ) Paper Code (ABC ..... ) Paper No. (1/2/3 ... .)
Space for photograph

a. I I I I I I
I I If Lll I I I I
b.
I I I I I I
IITTI g.O1 r II I I I n DO NOT PIN/STAPLE
the photograph
Paste the photograph
C.
I I I 0[1
I I h.
DI ur111 l_j inside the box only

d.
ITII]I II I 0 j. I I 1.
I
PHOTO NOTTO BE
ATTESTED
e.
ITIIIJ[l[TJJ I I I IDDITIJ
12. Particulars of examination passed:
Sl•niture oftheCIMldtte lnfuN I
SI. Examination passed University/Board Year Roll No. Division Subjects taken
No.
l.
2.
3.
4.

13. If debarred from appearing at any University/Board examination, state the name of
Examination ... .... .. .. ... . .. .... ............. .., Year ............... .. ........ .. ..... .. Roll No ................. ........ .. .... ..
Name of the Universitv/Board ..................... ... .... ......................... ... ......... .... ........ .... ..... ..............
14. Details of Lectures delivered/ Attendance:

Subjects / Papgrs No. of Lectures No. of Lectures Percentage of Remarks

.. '
delivered attended attendance
;

.
..
..
. .

D EC LA RAT IO N

I hereby declared that the Information provided Is correct to the best of my ~ge, In the event
of any lnfonnatlon being found Incorrect my candidature shall be liable to cancellation by lhe University.
I also undertake that I shall abide by the decision, rules and regulations of the University.

Signature of Candidate

CERTIFICATE

I certify that he/she has fulftlled all the requirements under the regulations to be eligible to appear at the
above ExaminaUon.
I certify that his/her conduct and progress in study Is satisfactory during the course study in this college.

Signature of the Principal /H.O.D •

Dated -. ......... ...................... . .•••.•••• .•• .••. •... •... •.. .College/Dept.
Office Seal

IMPORTANT INSTRUCTIONS FOR FILUNG THE FORM

• This Form will be computer Scanned.
• Do not fold the Form.
• Avoid overwriting.
• Keep the Form Clean and dust free.
• This Form Is to be filled In by the applicant In his/her own handwrlUng.
• Write all the particulars NEAnYIn CAPITAL/BLOCK letters with BLACK INK only.
• Do not use Photocopy/Xerox of this sheet. ·
• Do not make any sbay marks on this Form.