dtmnhrihgt ~nhrnathmal ®ptn & ®nlim ~ni&trsitu

Incorporated under Canada Not-for-Profit Corporation Act

Member of American Association for Higher Education, USA &
lndo Canada Education Council, Canada

APPLICATION FORM FOR HON ORARY DEGREE/ AWARD

(All Information should be in Block Letters)

Name of the Applicant

Mr./ Ms./ Mrs.I Dr ..... .. ... .... .. ... ........ .... ... ... .... .. ... ... ... ....... .. ... ..... .... .......................................... .

DOB:... ... .... .......... .. ... .... .. ..... ..... Age:.. ... ...... .. ... ... .... .... .. Gender:.... .... .. ... ........... .. .. ...... .... .

Blood Group: .. .. ....................... ..... Nationality: .... ..................... Religion:..... ........ .... .. ............. ..

Mother Tongue: .. ... .. ... .... .... ..... ..... Single or Married: .. ...... ...... Handicapped or any:.. .. .... .. .. ... .. ... ..

Father's/ Guardian's Name: .......... .. ... ... .... .. ...... .... ........ ..... ..... .. .. ... ..... .... .. ..... .. .. .... .. ...... ... ..

Address: ...... ... .... .... ... .. ....... ... ..... ........ ... .. .. ...... .. .. ...... ............. ...... ........... ..... .... ... ......... ..

District: .................. .. ..... .............. State: ...... .. .. .. .. ...... ............. Pin Code: .......... .. ......... ....... .

Mobile No.: .... ... .. ...... .................... Email: .. .. .................... ...... ......... .. ... ............. .. .... .. .. . ..

Educational Details:

Name of School/ College Year ' Subjects Percentage

SSC (10 111 )

HSC (12 th)

Under Graduation

Graduation

Post-Graduation

Other (s)

Field and Specialization: .. ...... .. .... .. .... ... .. ... ............. .. ... ... ......... .......... ... .. .... .. ....... .. ... . :.... ... .

lndla office: B-2, Shopping Arcade, The Surya Hotel, New Friends Colony, New Delhi-110025
Canada Office: 24, Noblesse Avenue, Ottawa, ON, K2G, 654, Canada
Email: info@clouniverslty.ca, Web: www.ciouniversity.ca, Tel: 011-40541446
Disclosure:

1. A short biographical summary (max 200 words), which will form on the basis of education, research.
thesis, or any other area of interest.
2. Attach Curriculum Vita with 4 passport-size photographs, including all the related educational
certificates & documents & a copy of a val id Passport/ Voter ID/ Aadhar Card or any other National
ID.

3. I am aware that the Honorary Doctorate Degree, if awarded to me shall not be used for academic &
jobs purposes.
4. 1also admit that fees once paid will not be refunded.
5. I hereby certify that all the particulars filled are true to the best ofmy knowledge.

Place: Signature

N ame: .............................. .. .

Address: ............................. .

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Contact N o.: ........................ .