NDIRA KALA SANGIT VISHWAVIDYALAYA Paste Passport Khairagarh, Chhattisgarh size photograph (Accredited with Grade “A’University by NAC) of the applicant APPLICATION FORM FOR ADMISSION ae Session 2017-18 (UG/PG/M.Phil./Diploma) wel ae aed Please complete each section in BLOCK LETTERS Name of the course in which admission is sought: rere ete FT eT eB 1. | Ful name (in BLOCK LETTERS) WRIA (Red a) D,_| Date of Bich (OD/MM/VYYY) HRMS (Resta / ae / as) 3,_| Father’s/Husband’s Name = (in BLOCK LETTERS) fe / aft a are (A A) Mother's Name (in BLOCK LETTERS): are ar ar (B= Guardian's name (in BLOCK LETTERS): caaraas ar aH (BL 9 6. | If guardians other than parent, please mention the relationship rat fter ae ne softer wear ETE BY : 7. | Occupation of parent : ses 1 ET 8. | Address for communication na wae 85 Pin Mobile no e-mail address Parent's Telephone Numbers (Residence and Mobile) 9, | Permanent Address ea oe Pia bee alain 10. | category et: | SCaen ST swat OBC aie GENERAL wee UY caste mnt: 12. _| Religion et ———S— 13. Nationality esi: _ 14. | Mother Tongue sr 15. | if Handicapped please specify aft Rrra & ot taet &16. | Marital Status fate eat Married feats Unmarried stare 17. | Bank Account Details te wren eae ‘Aadhaar No. sae 20 ‘Account No Name of Bank arm er fe a Branch Name : ee Branch IFSC: T8. | Details of examinations passed satel wrausem a Rew No. | Name of examinations Subject Name ofthe Board/Universty | Dwvsion/ | Year x passed ‘ee nse / Pee Grade | ot fel re why te es must be endlored ees we wR Note: Atested coples of related corti he eee HTT ex ce MT T9, | Class in which admission is sought aout Foret wer RA 20, | Main Subject a fava 21. | Optional Subjects ora faa, 22. | ifthe student is seeking re-admission, give details as under caf fell er wee ran oT wer & at Pree Par a: Name of the Class Subjects Date of admission Year of leaving Reason of leaving ai Rae sate FOL vist a1 af BIS BROT 23, | Hostel facility required aan t Yes et No wé Part-I ‘Anti-Ragging Declaration _ shall not participate in any act of ragging. If take part in ragging (which includes physical/mental injury to any student, teasing, insulting, cracking obscene jokes/songs, indecent behavior, rioting, scolding abusing etc.) or encourage it, | shall abide by the decision of the University that includes all the punitive measures pronounced by the government. a Pt Aner a8 Gr/eeh | ak A Ain A aT aor ae E SR Ret Reet a moe ste che darn/ sea, aoa wer, ses FeRa oer A YAM, AMT AGE TCT, ges WaT, tet, aah a1) suet oat wee oeT/ouh Eo Pangan freatarea eR A Ree ot oh sneer ariandt BH I, FSA ETH ART GIR MHA TA en evs saa em 8, yA ws eh] Name and Signature of the Parent/Guardian Name and Signature of the Student aren fen / aaa Br ATH Ye ETE faarit ar a qd SerePart -1l have carefully read the rules of the prospectus and shall follow them. None of the prohibitory provisions mentioned there applies to me. do hereby declare that the above entries made by me are true and that | shall abide by the rules/regulations that are in force and shall be brought out into force by the University from time to time. | shall accept the University instructions/orders in all disciplinary matters including the requirement of 75% attendance in the class. 9 Raetier 3 Pasi a art a qa 8 cen saET Get we /oeN| A ae der aear/aed EH Ren a ng wefan quar’ wea € oar ae PA ale cen afer A eI Ge ry eM are Peeler } Pras /siaPrat I ar Ba /aeth| § Raters Fw oer wet Geral /sreet Ga war 7s iter Tae A Prarie at dor weal /aet EI Name and Signature of the Student rene wr aH We SRT Name and Signature of the Parent/Guardian reife /afareas aT ae a weTERZ (For office use) All the required certificates of the student have been examined and found correct. Application form is forwarded along with all prescribed documents, (in-charge, UTD) (Recommendation) Part - | (Main Subject) ‘The performance of the student has been tested and found eligible/not eligible for admission. The Admission Test Committee has recommended/not recommended admission of the student in___ course. Member (1) Member (2) Member (3) Member (4) Date {Dean) Part - II (Minor Subjects) The Admission Test Committee has recommended/Not recommended admission of the student in Minor Subject - Minor Subject - 1 (Convener of the Admission Committee) Date: (Dean) (Special Permission) Special permission granted/Not granted. Date: (Vice Chancellor)