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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 Affix a recent passport
(DISTANCE MODE) 2019 – 2020 size self-attested
colour photograph

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

(See Prospectus)

3. Name of the Learner

Support Centre

(See Link V in Prospectus)

4. Learner Support 5. Aadhaar No.

Centre Code
(See Link V in Prospectus)

6. Applicant’s Name
(In Capital Letters)

7. Father’s Name

8. Mother’s Name

9. Date of Birth 10. Gender

(DD/MM/YYYY)

11. Applicant’s Category

(mention subcategory if any)
(See Category Code overleaf)

12. State of Domicile 13. Nationality

14. Mobile No. 15. Alternate Mobile No.

16. Email ID

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

(In case of Refund of Fee)

18. Mailing Address: 19. Permanent Address:

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

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

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20. 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 No. of Application Form Fee _______________ Date _________ Drawn on _________________________________ Amount._________

DD No. of Programme Fee ______________ 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 candidate

CATEGORY CODE

General (G) Women (W)

Scheduled Tribe (MST) Schedule Caste (SC)
Other Backward Class with subcategory (OBC) Persons with Disability (PD)
Scheduled Tribe (ST) Scheduled Caste (SC)
Transgender (T)

Once opted for, category change is not permissible.