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Registration No.

__________________
Total No. of Enclosures_____________

REGIONAL INSTITUTE OF EDUCATION
(National Council of Educational Research & Training)
AJMER - 305004
Application Form for Admission
Session: 2014-15

1. Tick the Course applied for: Two Year B.Ed.(Secondary) M.Ed.(Elementary Education)
2. State/UT against which Admission is sought for _______________________________________
(For candidates who have passed qualifying examination
from the States/UT of Northern Region. Please see Point
No. 04 (i) (a) and (b) of the Information Brochure)
OR
State/UT against which Admission is sought for _______________________________________
(For candidates who have passed qualifying examination
from other than the States/UT of Northern Region.
Please attach either Domicile Certificate or Employee's
Ward Certificate as required under point No. 4(ii) of the
Information Brochure)
3. Subjects opted for Two Year B.Ed.(Sec.) (Teaching Subjects) 1. ___________________ 2. _________________
(For details, please see point 2 of the Information Brochure)

4. Tick the Category to which you belong: GEN SC ST OBC
(Attach Certificate)
5. (a) Whether you belong to PH Category ? Yes No
(b) If Yes, please tick appropriate box Visually Impaired Hearing Impaired Orthopaedically Handicapped
6. Tick the minority group to which you belong: Muslim Christian Sikh Parsi Buddhist Jain

7. Name of the candidate in Capital Letters
as mentioned in your Matriculation
Certificate
(Leave one box blank between first name, middle
name and surname)

8. Fathers name ______________________________________________________
9. Mothers name ______________________________________________________
10. Husbands / Wifes name ______________________________________________________
11. Guardians name ______________________________________________________

12. Date of birth (Attach Certificate) DD MM YYYY

13. Sex (Please Tick) M F
14. Nationality _____________________________________________________
15. Application Fee: IPO/Bank Draft No.Date...Rs...
(Rs. 300/- for Gen. & OBC and Rs. 200/- for SC/ST/PH candidates)
For Office use only
Category _____________
Percentage of Marks: 1. B.A./B.Sc. ___________2. B.Ed. Theory ___________ Practice ____________Aggregate __________
Percentage of Marks: M.A./M.Sc./M.Com. _________________________

Credit Marks________


TCM Cont2


Affix Recent
Passport Size
Photograph here
1. Checking Officer_________________________
2. Verifying Officer ________________________



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16. Educational Qualification(s) (Attach Mark sheets year-wise)

S.
No.
Examination Year
Subjects
(Only Optional)
Board/University
Max.
Marks
Marks
Obtained
Percentage
of marks
Div.

1.

B.A./B.Sc. Part I
Part II
Part III
TOTAL
2. M.A./M.Sc./M.Com
Previous

Final
TOTAL

3. B.Ed. Theory
Practice
TOTAL
4.

B.Sc. B.Ed./ Part I
B.A. B.Ed.











Part II
Part III
Part IV
TOTAL

17. Name of the Institution and State from which the candidate has passed
I For Two Year B.Ed. (Secondary) candidates
B.A./B.Sc. or equivalent
Name of the Institution _________________________________ State _____________________

Name and place of the Examination Centre ___________________________________________
II For M.Ed. (Elementary Education) candidates
B.Ed. or equivalent
Name of the Institution __________________________________ State ____________________

Name and place of the Examination Centre ___________________________________________
18. Home Town Village/Town_______________Dist._________________State_______________
Nearest Rly. Station Place:_________________________State:_______________________________
Nearest Bus Stand Place:_________________________State:_______________________________
19. Permanent Address _________________________________________________________________
____________________________________________PIN__________________
Telephone No. (with STD code) ________________ Mobile________________
e-mail address _________________________________________________

Cont3


Application Form for Admission
Session: 2014-15




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Declaration by the Candidate
I hereby declare that all the information furnished in this application form is true and correct
to the best of my knowledge, and if anything found false at any stage, my candidature/admission may
be cancelled.

Place: _______________
Date: _______________
Signature of the Candidate
List of enclosures:
1. _______________________________________ 2. ______________________________________
3. _______________________________________ 4. ______________________________________
5. _______________________________________ 6. ______________________________________
7. _______________________________________ 8. ______________________________________

Important Instructions. Before submitting the application, please ensure and Tick ( )
1. Recent photograph affixed.
2. Self attested photocopies of the following documents have been attached:
A. Caste Certificate for SC/ST /OBC (non creamy layer) candidates only
B. Physically Handicapped Certificate (if required).
C. High School/Secondary Examination Mark sheet/certificate showing date of birth.
D. All mark sheets about which details have been given at point no. 16 of the form.
3. Photocopy of Domicile Certificate attached.
(if required as per point 4 of the information brochure)
4. Employees Ward Certificate attached.
(if required as per point 4 of the information brochure)
5. IPO/Bank Draft for Rs. 300/- or Rs. 200/- (as the case may be) attached.
6. The candidate has signed the form at the appropriate place.


Note: Incomplete application form in any respect will not be considered



Please fill in your mailing address on the following slips :-


Name: ..
Address% ..



PIN CODE: PHONE.......


Name: ..
Address% ..



PIN CODE: PHONE.......



Application Form for Admission
Session: 2014-15