ANNAMALAI UNIVERSITY

APPLICATION NO.

DIRECTORATE OF DISTANCE EDUCATION

Application for Admission to
Preparatory / Pre-Foundation / Certificate /
Diploma / P.G. Diploma / Under Graduate /
SPOT CODE
Post Graduate / Double Degree Programme
including Lateral Entry 2014 - 2015
(REFER PROSPECTUS FOR DETAILS) (Make a tick-mark (
) in square q
wherever applicable)

FOR OFFICE USE ONLY

ENROLMENT NO.

1. Programme
Code & Name

PASSPORT SIZE
PHOTO
Double Degree Programme
q
Lateral Entry/Direct II / III Year Programme q
duly signed
and attested
2. PCP Zone (See Prospectus)
Medium: English q
Tamil q
by an authorised
officer
3. OPTIONAL SUBJECT CHOSEN : (See Prospectus)

Preparatory, Pre-Foundation Programmes:

Part - I

Part - III

U.G. Programmes : Part-I :

Optional Papers : I Year:

II Year:

III Year:

P.G. : I Year:

II Year:

Programmes (optionals)

4. Name in CAPITAL LETTERS (In English):

5. Fathers Name / Husbands Name

6. ADDRESS IN CAPITAL LETTERS (to which communications and lessons are to be sent)

PIN
Dist.
Phone No.
(with STD Code)

State
E-mail ID

Mobile No. :

7. Date of birth (in the Christian era)

(as entered in the School Leaving Certificate)
8. Sex:

Male

Date

Month
1

Female q
q
Muslim q
Christian
q

11. Community :

SC

12. Differently Abled: YES

ST

9. Nationality:

10. Religion: Hindu

SCA

Year

Others (specify)
q
MBC

BC

BCM

q
NO q
Blind q
Others

13. Qualifying Examination Passed:

Duration of
Name of the
Programme
Examination

Name of the
University/Board

OC

DNC
Percentage

Reg. No.
and Year

Main :
Ancillary :
Application Fee ` 100/- in person and ` 150/- by post.

%
of Marks

Class
Obtained

11+1+3 q
10+2+3 q
11+2+2 q
(Direct OUS UG & PG Degree are not Eligible)

14. Pattern of passing

the Degree Examination:
15. Occupation :

Government

16. Are you presently undergoing any

other programmes, in any institution
(including DDE)? If yes, give details :
17. Option for Study Material:

Yes

Hardcopy

Non-Government q
Others q
q

No q
q

Softcopy q
q
DECLARATION

i) I declare that the particulars given above are correct and I submit myself to the disciplinary and regularly jurisdiction of the authorities of
the

University who are vested with the rights to exercise discipline under the Act, the Statutes, and the Ordinances, and will strictly observe

the rules and regulations that have been framed thereunder by the University.
ii) I hereby agree that with regard to disputes arising in all matters including admission, returning of original certificates after verification,
sending of lessons, PCPs, response sheets, examinations, remittance of fees, etc., only the Courts and Tribunals having jurisdiction over
Annamalainagar (Chidambaram), Cuddalore District, Tamilnadu and not over any other place, shall have jurisdiction for the purpose of filing a
suit or preferring complaint under the Consumer Protection Act or any other law for the time being in force or for taking any legal action against
the Directorate of Distance Education or the Controller of Examinations, Annamalai University.

Place:
Date:

Signature of the Applicant

(5) Photostat Copy of Community Certificate q

Enclosures: (1) Photostat Copy of Degree Certificate/Pass / Provisional Certificate q
(Check List) (2) Photostat Copy of Mark List or Consolidated Mark List
(6) Scanning Slip
q
q

(7) Community Certificate

q
q (except OC)

(3) Photostat Copy of Transfer or Migration Certificate

(4) Identity Card duly filled in

(Do not enclose original certificates)

FOR OFFICE USE ONLY

CERTIFICATES VERIFIED
1) Degree/Provisional/Pass Certificate
2) Transfer OR Migration Certificate
3) Mark List (10th/12th Standard)
4) 8th Standard Transfer Certificate
5) 10th Standard Transfer Certificate

ELIGIBLE

NOT ELIGIBLE q
q

REMITTANCE PARTICULARS
Name of the Bank
q
Draft/Challan Number
q
Amount
q
Date
q
q

:
:
:
:

Provisionally selected for admission. Spot selection subject to confirmation by the Director

Official-in-Charge

Section Head

Officer-in-charge

For use in Spot Admission

Whether Original Certificate/Mark Lists
No q
received after verification? Yes q

Whether Lessons received

Yes q
No q
Incomplete set q
If yes, Complete set q

Signature of the Candidate

Admission Confirmed

Official-in-Charge

Section Head

DIRECTOR