International Institute for Population Sciences

Govandi Station Road, Deonar, Mumbai - 400 088.

(DEEMED UNIVERSIT!
(Te"e#ra$%i& 'ddre(() DEM*GR'+,, -%embur, Mumbai!
APPLICATION FOR ADMISSION TO
DPS COURSE
(Throuh Distance E!ucation"
Processin Fe e #
'mount ) US . /0
(1orei#n!
) R(. 4002-
(Indian!
D.D. No. )
I((ued at )
Date )
'33i4 '
Se lf Atte s te!
Rec e nt
+a(($ort
Si5e
+%oto#ra$%
1. Name in 3u"" ) Dr.2Mr.2M(.2Mr(.

(IN 67*-8 7ETTERS!
2. Se4 ) 9. Nationa"it: ) 4. Marita" Statu( );
5. (a! 'ddre(( 3or &orre($onden&e)
(b! +ermanent 'ddre(( )
(i3 di33erent 3rom t%e above!
(&!
(d!
E-mai" )
+%one Number )

*33. ;Re(i. Mobi"e
6. Date and +"a&e o3 6irt% )
7. <%et%er be"on# to S-2ST2*6- No2e( (S$e&i3:!
(I3 a$$"i&ab"e!
8. Aca!e$ic Recor!
Give $arti&u"ar( o3 a"" t%e e4amination( and de#ree( obtained
E4am2De#ree 6oard2In(titute2
Univer(it:
ear o3 +a((in# Divi(ion2-"a(( =it%
$er&enta#e o3
mar>( obtained
Sub?e&t((!
o33ered
#Non-re3undab"e
9. Give rea(on( in brie3 a( to =%at do :ou e4$e&t to #ain 3rom t%i( $ro#ramme
('tta&% additiona" $a#e i3 re@uired!
%&' E$plo($ent Recor! (if an("
Em$"o:er +o(t %e"d 1rom
(Date!
To
(Date!
Sa"ar: "a(t dra=n Rea(on( 3or "eavin# t%e $o(t
DECLARATION )* T+E APPLICANT
I %ereb: de&"are t%at a"" (tatement( made in t%i( a$$"i&ation are true, &om$"ete and &orre&t to
t%e be(t o3 m: >no="ed#e and be"ie3.
+"a&e A Date)
Si#nature o3 t%e '$$"i&ant
CERTIFICATE )* T+E EMPLO*ER (If applica,le"
T%i( i( &erti3ied t%at Dr.2Mr.2M(.2Mr(.

%o"d( a $o(t o3
in t%i( De$t.2*33i&e2In(titution and a"" t%e (tatement( made b: %im2%er in
t%i( a$$"i&ation are &orre&t to t%e be(t o3 m: >no="ed#e and be"ie3. I re&ommend %i(2%er admi((ion
to t%e D+S $ro#ramme o3 t%e In(titute.
+"a&e A Date)
Si#nature)
De(i#nation)
De$t.2In(titution2*r#ani(ation)
(*33i&e Sea"!
Note :-
1. Appli c atio n s should be sent by regi s tered po s t/c ouri e r to the In-charge, Department of Extra Mural
tudies, International Institute for !opulation ciences, "II!#, $o%andi tation &oad, Deonar, Mumbai -
'(( ()), India, so as to reach on or before 31
st
July 2013.
2. *ompleted application form and copies of transcripts attested by a $a+etted ,fficer or public notary
should be submitted along -ith a processing fee of &s.'((/- ".or foreign student / 01# through a
demand draft payable to 23he Director, International Institute for !opulation ciences, Mumbai4.
3. */3 candidates are exempted from paying the processing fee
4. Appli c a n ts -ho are selected for admission to the course - ill be informe d by &egistered post/E-mail.
5. INCOMPLETE FORM WILL BE SUMMARILY REJECTED.