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Centre for Distance and Open Learning


Jamia Millia Islamia
Gate No. 20, Maulana Mohammed Ali Jauhar Marg,
New Delhi – 110025
Application Form for Admission to Diploma and Certificate Programme Affix a recent passport
(DISTANCE MODE) 2018 – 2019 size self-attested
colour photograph

Roll No.
(To be filled in by the office)
(To be filled in capital letters using Blue/Black Ballpoint pen only)

1. Programme Applied for

(See Programme List in Admission Notification - I)

2. Programme Code

(See Programme List in Admission Notification - I)

3. Name of the Study Centre

(See Annexure II in Admission Notification-I)

4. Study Centre Code 5. Aadhar No.

(See Annexure II in Admission Notification-I)

6. Applicant’s Name

7. Name of Father/Mother/Spouse

8. Date of Birth 9. Gender

10. Applicant’s Category


(See Category Code overleaf)

11. State of Domicile 12. Nationality

13. Mobile No. 14. Alternate Mobile No.

15. Email ID

16. Bank Details A/c No. Bank Branch IFSC Code

17. Mailing Address: 18. Permanent Address:

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………
19. Educational Qualifications:

Examination Board/ Course Subjects Result/ Year Marks Total %age CGPA
University Awaited Obtained Marks
X

XII

Bachelors

Masters

Others

DECLARATION BY APPLICANT

I SOLEMNLY UNDERTAKE to accept and abide by the rules of the Jamia Millia Islamia and all the decisions of the Admission Committee and
other appropriate University bodies in regard to my admission.

I SOLEMNLY AFFIRM that I have never been convicted by a court of law nor rusticated/expelled from any educational institution /nor
disqualified/debarred from any examination.

I will accept the cancellation/ forfeiture of my candidature in case any information supplied by me in this form is found to be incorrect at the
time of admission or thereafter.

Signature of Father/Guardian Date Signature of Applicant

DD/Pay Order No.__________________ Date ________________ Drawn on __________________________________ Amount.______________

Note: The Application Form should be submitted along with Demand Draft of Rs. 500/- in favour of Jamia Millia Islamia,
payable at New Delhi.

Transgender Candidates: No admission application form fee or programme fee will be charged from transgender candidates.

CATEGORY CODE

General (G) Other Backward Class (OBC)


Schedule Caste (SC) Schedule Tribe (ST)
Transgender (T) Persons with Disability (PD)