ANNEXURE-I

ADMISSION-CUM-EXAMINATION FORM
FORM NO

ENROLMENT NO.
(for oce use)

DIRECTORATE OF DISTANCE EDUCATION

GURU JAMBHESHWAR UNIVERSITY OF SCIENCE & TECHNOLOGY HISAR

APPLICATION FORM FOR ADMISSION TO DISTANCE LEARNING PROGRAMME

SESSION 2013-14
The applica on form lled in by the student along with requisite fee, copies of cer cate and student
iden ty card must reach the Director, Distance Educa on, G.J. University of Science & Technology,
Hisar before the last date
Fill in the following table (choose only one programme)
Programme
Applied for

Fee Details
DD / UR No.

Date

Space
for
Photo
(A ested)

Amount

HDFC A/c No.

01551450001129
PNB A/c No.
0203021100000023
UBI A/c No.
344302050000103

1.

Name of Candidate (In Eng.)

(as in Matricula on Cer cate)
(In Hindi)

2.

(a) Fathers Name (In Eng.) Sh. ...

(In Hindi) Sh. .
(b) Mothers Name (In Eng.) Smt. .
(In Hindi) Smt. ..
Note: Candidate must ll up column No.1 & 2 in both the languages and in Capital Le ers in English

3.

(a) Postal Address (use capital Le ers)

.PIN Code ..
(b) Permanent Address (use capital Le ers)
.PIN Code
(c) Phone No. with STD Code/Mobile No.
(d) E-mail Address ..

4.

Date of Birth Day.Month.Year

5.

Educa on Qualica ons :

Examina on

Board/University

Year of
Passing

Marks
obtained

Total
Marks

(a) Matric
(b) 10+2 or its equivalent
(c) BA/B.Com/B.Sc/BMC/BBA/BCA
(d) BJMC/PGDMC/PGDAPR
(e) PGDCA/PGDCSA/PGDCS/Post BA or B.Sc./DCA/BIT
or BIS(4 yrs)/A Level of DOEACC (a er gradua on)
(f) M.Sc.(Com.Sc.)/M.Sc.(So ware)/M.Sc.(IT)/MIT
(g) Any other examina on

5(a).

Whether Entrance Test Qualied

(Applicable to MBA/MCA-3 yrs/MCA-5 yrs. Integ.)

Yes/No

(Tick Mark)

5(b).

Name of the test on the basis of which

Exemp on from Entrance Test Claimed

MAT/CAT/Any other Equivalent Test

(Pl. a ach self a ested photocopy)

%age of
marks

6.

7.
8.

Are you an old student of the Directorate ( ck the column)

Yes
No
If yes please men on
i)
Name of Course: ...
ii)
Enrolment No. : ....
iii)
Result
: ....
(a)
Na onality
(b) Country of Residence
General Informa on (Tick Mark only relevant column)
(a)
(b)

Sex:

Male

Female

Category:
General
SC
(a ach documentary evidence of Reserved Category)

BC/OBC

PH

Self/Wards/Spouse of GJUS&T Regular Employee/GJUS&T Audit Sta/Directorate of Technical Educa on, Haryana Sta

9.

Were you ever disqualied by any University/Board to appear in any examina on?
If yes, give details
..

10.

Op on of Language in case of BMC Candidates:

11.

Choice of City for centre of Examina on (Applicable only in the case of direct students)
1..

12.

Hindi

English

3
.

List of Enclosures:
(a)

(b)

(c)

(d)

_______________________________________________________________________________________________________
DECLARATION BY THE APPLICANT
I hereby declare that I have read and understood the condi ons of eligibility for the programme for which I seek admission. I
fulll the minimum eligibility criteria and I have been provided with necessary informa on in this regard. In the event of any
informa on found incorrect or misleading, my candidature shall be liable to cancella on by the University at any me and I
shall not be en tled to refund of any fee paid by me to the University. I have received a copy of prospectus supplied by the
University.
Full Signature of Candidate
UNDERTAKING
(Only for those candidates who have appeared in qualifying examina on and result has not been declared as yet)
IS/o / D/o Sh. .. hereby undertake that I stand appeared in examina on
conducted by Board/University held in I am seeking admission in course at my own risk and
responsibility and I will submit the proof of my having cleared the qualifying exam, which is required for admission to the
above course by 31.12.2013 failing which my candidature shall stand automa cally cancelled and I will not make any claim in
any court of law on this account.
Place:
Date: .

Full Signature of Candidate

Signature with seal of the

Head of the Study Centre
(for oce use)
Eligibility subject to submission of following documents:

(for oce use)

Not eligible due to

1.

..

1.

..

2.

..

2.

3.

..

3.

Clerk/Ass .

DS / Supdt.

DD(DE)

Clerk/Ass .

DS / Supdt.

DD(DE)