Admission Form Admission Form

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Admission Form

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Content

No.:

UNIVERSITY
Established by UP State Govt. Act 23 of 2010 & U/S 2 (f) of U.G.C. Act 1956

N.H. 24, Delhi Hapur Raod, Village & Post Kastla, Kasmabad, P.O Pilkhuwa - 245101, Dist. Hapur (U.P.), India

NEW ADMISSION FORM
SESSION..............................

Paste a latest colored photograph of candidate and attach 3 additional copies also

Counseling Centre Code _____________________________________ Counseling centre Name & Address ___________________________________________________ ___________________________________________________ Course Details Course applied for Personal Details Name
(Block Letters)

Branch

Year

E-mail ID Landline No. Father ’s Name (In Black Letters) Mother ’s Name (In Black Letters) Date of Bir th Permanent Address Mobile

Parent's Contact No. Parent’s Occupation Nationality Blood Group Category (Tick) General
(Attach Proof)

Annual Income
(Attach Proof)

Gender (Tick) Male

Female

SC

ST

OBC

Others

Local guardians’ Name & Address Landline No. Mobile No.

15. Academic Qualification (Star ting from X or Equivalent of the cer tificate) (Enclose attested photocopies)
S.No. Examination Passed Name of Board/University Year Marks Obtained % of Marks

1. 2. 3. 4. 5.

High School 10+2/ITI/Dip
Graduation

Post Graduation M.Phil.

16. Hostel Accommodation Required (Tick) Yes Yes 17. Transport Facility Required (Tick) 18. Co-curricular Achievement(s) NCC/NSS/Sports/Cultural Activities (Attach Proof) 19. Any Professional/Academic Achievements (Attach Proof) 20. A) Declaration by the Candidate

No No

I hereby declare that the information given above is true and complete to the best of my knowledge & belief, and if any of it is found to be incorrect my admission shall stand cancelled and I shall be liable to such disciplinary action as may be decided by the University. The decision of the University there on shall be final. Place Date B) Declaration by the Parent's/Guardian I under take the responsibility of paying all dues of my son/daughter regularly and I bind myself for his/her dues compliance with all rules and regulation that are in force form time to time in the University. Place Date
Enclosure: Check List (Tick Whichever is applicable)
1. Date of Bir th Cer tificate. 2. Attested Cer tificates and Mark sheets of class X, XII and Graduation. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Character Cer tificate. Signature Medical Fitness Cer tificate. Migration Cer tificate from the last Board/University. Cast Cer tificate in original visible on the website of revenue bor. up.nic.in. Seven Passpor t size coloured photographs. Permanent Residence Proof. Gap Cer tificate (If any during studies) Anti ragging Affidavit by Student and Parents/Guardian. Two self addressed envelopes (with stamp of Rs. 25/-) Income Cer tificate inoriginal visible on the website of revenue bor.up.nit.in“

Signature of the Student

Signature of the Parents/Guardian

& Stamp of Counseling Centre

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