GITAM UNIVERSITY GITAM UNIVERSITY GITAM UNIVERSITY GITAM UNIVERSITY GITAM UNIVERSITY

(Declared as Deemed to be University U/S 3 of UGC Act, 1956)

VISAKHAPATNAM530 045 (A.P.)
Examination Application Form
(Only for First Semester/Trimester and Supplementary cadidates)
Paste recent
passport size
photograph (to be
attested by the
Head of the
Department /
First year
Coordinator.
1. Examination Appearing for
(i) Program :.............................................................................
(ii) Branch : ......(iii) Branch Code
(iv) Semester/Trimester :................................. (v) Month & Year of the Examination :.........................
2. Name in full with surname as per SSC or equivalent (in capital letters)
4. Date of Birth 5. Sex: Male / Female
6. Category: SC/ST/OBC/Others 7. Native of Rual or Urban
7. Fathers Name
Mothers Name
8. Permanent address Address for correspondence
9. Fee: First Semester / Trimester candidates need not pay examination fee.
Fee for supplementary candidates:
one subject: Rs.300/- Two subjects: Rs.500/- Three or more subjects: Rs.750/-
Amount paid: Rs.....................; Rupees...........................................................................only (in words)
Name of the Bank: Challan / D.D. No.: Date:
Enclose: (i) Original bank challan/D.D. (ii) Photo copy of S.S.C. or equivalent certificate to the application
Date : Signature of the Candidate
For Office Use Only
Recommended for the issue of Hall Ticket subject to the candidate fulfilling all eligibility criteria.
Not recommended because ................................................................................................................
Signature of
Head of the Department
Regd. No.
Name Surname
Date Month Year
Pin: Pin:
email: contact number: