Admission Form Admission Form

No.:

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

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

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

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

Counseling Centre Code _____________________________________ Counseling centre Name & Address ___________________________________________________ ___________________________________________________ Course Details Course applied for

Branch

Year

Personal Details Name (Block Letters)

E-mail ID Landline No.

Mobile

Father’s Name (In Black Letters) Mother’s Name (In Black Letters) Date of Bir th Permanent Address

Parent's Contact No. Parent’s Occupation

Annual Income (Attach Proof)

Nationality

Gender (Tick) Male

Blood Group Category (Tick) General

SC

ST

OBC

(Attach Proof)

Local guardians’ Name & Address Landline No.

Mobile No.

Others

Female

15. Academic Qualification (Star ting from X or Equivalent of the cer tificate) (Enclose attested photocopies) S.No.

1. 2. 3. 4. 5.

Examination Passed

Name of Board/University

Year

Marks Obtained

% of Marks

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

Signature of the Student

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

Signature of the Parents/Guardian

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“

& Stamp of Counseling Centre