Link-IV

Centre for Distance and Open Learning

Jamia Millia Islamia
Gate No. 20, Maulana Mohammed Ali Jauhar Marg, Affix a recent passport
size colour photograph
New Delhi – 110025 duly attested by the
Application Form for Admission competent authority
(For Indian Defence Personnel)
(DISTANCE MODE) 2019 – 2020
Service: Indian Army Indian Air Force Indian Navy Indian Coast Guard
(Please tick mark whichever is applicable)

Roll No.
(To be filled in by the office)

(To be filled in capital letters using Blue/Black ball pen only)

1. Programme Applied for

(See Prospectus)

2. Programme Code 3. Enrolment No.

(See Prospectus) (If earlier allotted by JMI)

4. Name of the Defence Defence Station/ APO

Station/Unit Unit Pin
5. Applicant’s Name

6. Father’s Name

7. Mother’s Name

8. Service No. Check Suffix 9. Branch

Service joining date

10. Date of Birth 11. Gender

(DD/MM/YYYY)

12. State of Domicile 13. Nationality

14. Mobile No. 15. Alternate Mobile No.

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

(In case of Refund of Fee)

17. Email ID 18. Aadhaar No.

19. Address for receiving Self Learning Material: 20. Permanent Address:
……………………………………………………… ………………………………………………………

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

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

……………………………………………………… ………………………………………………………
21. Educational Qualifications:

Examination Board/University Subjects Year Division %age

XII

Bachelors

Masters

Others

22. Service Training/Courses Undertaken:

Name of the Service Course Course Duration Place

From To Total Period

23. For Indian Navy: Select any one of the following Indian Navy Centres for collection of Study
Materials, Submission of Assignments and Term-End-Examinations.
Delhi Mumbai Vishakhapatnam Kochi

24. For Indian Coast Guard: Select any one of the following Examination Centres nearest to the parent
unit.
Delhi Gandhi Nagar Mumbai Chennai
Kolkata Portblair

25. Medium of SLM

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 Applicant Date Signature of Competent Authority

(Unit Adjutant/CO)

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

DD No. _______________________ Date ________________ Drawn on _________________________________________ Amount.______________