10/18/2019 Print Application Form / Challan

seal of
the receiving
centre NETAJI SUBHAS OPEN UNIVERSITY
DD-26, Sector-I, Salt Lake City, Kolkata - 700 064.
APPLICATION FOR STUDENT ENROLMENT
YEAR : 2019-2020 SESSION : JANUARY 2020

To be submitted at the chosen Study Centre within stipulated date along with photographs and attested photocopies of relevent documents.
Application No : PA19011876 Date :18/10/2019 08:40:55 AM

The Study Centre (SC) provisionally allotted as chosen by the applicant :

SC Code No : D-01 Name : Krishnanagar Government College Study Centre
District : Nadia

Programme Details :
Programme Name : Post Graduate Programme Programme Code : PG
Stream : MA Preferred Language for Study Material : Bengali
Elective Subject : PGPS

Applicant's Name, Address & Other Details

Name : AJIJUL SK
Gender : Male
Category : General State of Domicile : West Bengal
Guardian's Name : AZARUDDIN SK
Father's Name : AZARUDDIN SK
Mother's Name : NURUNNECHHA SK
Spouse's Name :
Present Address : Vill-Gaharapota, P/O-Dingel,P/S-Kaliganj
Pin No : 741137
Permanent Address : Vill-Gaharapota, P/O-Dingel,P/S-Kaliganj
Pin No : 741137
Mobile No : 8001608104
Telephone No : Email : ajijul8001608104@gmail.com
Date of Birth (DD-MM-YYYY) : 15 / 02 / 1993
Marital Status : Unmarried
Whether Physically challenged : No Type of Disability :
Candidate's Occupation : Self-employment
Defence & Security Forces : No Type :
Whether belong to BPL : No
Monthly Income of the family : Less than Rs. 5000/-
Aadhaar Card No : 709056374798
Nationality : INDIAN
Religion : Islam
Residential Area : Panchayat
Govt. Issued ID Proof : Adhaar Card ID Proof No : 709056374798
Whether already registered in NSOU : No

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Academic Record :

Year of % of
Examination Passed Board/University Subject Studied
Passing marks
Bengali,English,mathematics,History,life sci-
Secondary WBBSE 2009 47%
ence,physical science,
Bengali,English,History,Political science,Ec-
Higher Secondary WBBHSE 2011 51.5%
o Geography.
West Bengal State Univer-
Bachelor Degree 2014 Bengali,Political science,History 42%
sity

Note : Self attested Copies of age proof document, Mark sheets, and all other relevent documents must be enclosed with the
Application Form.

DECLARATION BY APPLICANT

I hereby declare that I have read and understood the condition of eligibility for the programme and for the elective subject for  which I seek
admission. I fullfill the minimum eligibility criteria and I have provided necessary information in this regard. In the event of any information being
found incorrect or misleading my candidature shall be liable to cancellation by the University at any time and I shall not be entitled to refund of any
fee paid by me to the University.

I understand that my admission in the above mentioned course at respective Study Centre is provisional and will be guided in accordance to UGC
approval vide F. No. 1-6/2018 (DEB-I) dated 09.08.2018 The University reserves the right to change / reallocate the Study Centre chosen by the
learners in order to regulate the admission in accordance with UGC order(s) if any.

Place :........................................... Date :...........................................

Countersigned
Co-ordinator :.................................(Study Centre) ..................................................................

Seal of the Study Centre Full Signature of the Candidate

Sr. No. Application History

1 Submitted on: 18/10/2019 08:40:55 AM

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