Form No......................................

Teerthanker Mahaveer University

Delhi Road, Moradabad (U.P.) - 244 001

Application Form

Please paste your

recent coloured
passport size
photograph
here

(Session 2012-2013)

Signature of the Candidate

1. Program Applied for............................................................................................................................................................

2. Preference for branch/specialization in case of B. Tech. / MBA/ M. Tech/M.Sc. Medical/

M. Sc Home Sc./M. Pharm/M.Sc. Nursing/MDS/MD/Diploma in Engineering programs.

1.

2.

3.

4.

5.

6.

7.

8.

3. Name of the candidate.....................................................................................................................................................

(English)

(Hindi)

(in capital letters as per matriculation certificate)

4. Date of Birth............................................................................................................5. Gender (M/F)...............................

6. Fathers Name.......................................................................................................................................................................
(English)

(Hindi)

7. Mothers Name......................................................................................................................................................................
8. Category (General/OBC/ST/SC/Others).......................................................................................................................
9. Residence Status..................................................................................................10. Blood Group...............................
(Village/Town/City)
11. Parents Occupation: Father............................................................................. Mother..................................................
12. Parents Education: Father................................................................................ Mother...................................................
13. Family Annual Income (Rs.)................................................................................................................................................
14. State of Domicile.................................................................................................. 15. Mother Tongue...........................
16. Religion....................................................................................................................17. Nationality.....................................
1/4

18. Details of Examination Passed/Appeared

Examination

Year of
Passing

School/
College

Name of
Board/Univ.

Max.
Marks

Marks
% of
Obtained Marks/
Grade

Medium Discipline/
of
Subjects
Instruction

10th (Secondary)
12th (Sr. Secondary)
Graduation
......................................
(Please specify degree)

Post Graduation
......................................
(Please specify degree)

Professional Degree
......................................
(Please specify degree)

Other Qualifications
......................................
(Please specify)

19. Correspondence Address:........................................................................................................................................................

City/Village..................................................Post................................................ Police Station..............................................

Railways Station........................................ District.......................................... State...............................................................

Pin Code...................................................... STD Code..................................... Telephone No..............................................

20. Parents Contacts:

STD Code.................... Tel No...................... Mobile No................................... E-mail.............................................................

Student Contacts:

STD Code.................... Tel No...................... Mobile No................................... E-mail.............................................................

21. Name of Entrance Examination: Detail information in case of CAT/MAT/XAT/ATMA/

UPSEE-2012/UPCMET-2012/UPCAT-Dental-2012/CPMT- 2012/AIEEE-2012/ Other Recognized Tests

Test.................................................................Year/Month................................. Score............................... Rank....................

(Please attach the certified photocopy of the result)

22. Work Experience (If any): Organization....................................................................... Experience (yrs).......................

Undertaking:
I solemnly affirm that the information furnished above is true and correct in all respect. I have not concealed any information.
I undertake that if any information furnished herein is found to be incorrect or untrue, I shall be liable to criminal prosecution
andalso forgo my claim to admission to the University. Further, my candidature for the examination/admission to the program
shall beliable for cancellation at any stage. I agree to abide by the rules and regulations of the University.

Date Signature of Parent/Guardian Signature of Candidate

Note: Attach documents as per Annexure A alongwith the filled in application form at the time of admission. Submit all pages (1/4 - 4/4)
2/4

Annexure-A
List of documents
(To be attached by the student, whatever is applicable, with the filled in Application Form)
1. Attested photo copy of High school (10th Standard) Mark Sheet
2. Attested photo copy of High school (10th Standard) certificate
3. Attested photo copy of Intermediate (12th Standard) Mark Sheet
4. Attested photo copy of Intermediate (12th Standard) certificate
5. Attested photo copy of Mark Sheet of B.A./B.Sc./B.Com/B.B.A/BCA/B. Tech/BDS/MBBS Equivalent
Examination (all semesters/years/consolidated one)
6. Attested photo copy of B.A./B.Sc./B.Com/B.B.A/BCA/ B. Tech/BDS/MBBS/ Equivalent Degree
7. Attested photo copy of Mark Sheet of M.A./M.Sc./M.Com/M.B.A/MCA/M.Tech./Equivalent Examination
(all semesters/years/consolidated one)
8. Attested photo copy of M.A./M.Sc./M.Com/M.B.A/MCA/M.Tech./Equivalent Degree
9. Attested photo copy of Result card of Entrance Test (if applicable)
Following documents to be submitted on confirmation of admission:
a Transfer certificate in original from last Institution attended
b Migration in original from last Board/University attended
c Character certificate in original from last Institution attended
d Gap year Affidavit (if any)
e Affidavit on Non-judicial stamp paper of Rs. 10 for abiding university rules and regulations
dulysigned by student & parent.
f

Anti-ragging undertaking duly signed by student & parent.

g Caste certificate in case of SC/ST/OBC student

h Parental income certificate (Required only in case of parental annual income less than Rs. 1 Lac)
i

Physically handicapped certificate (if applicable)

Medical certificate on pre-prescribed proforma

k Recent passport size coloured photograph (6 Nos.)

Note:
1. Please tick ( ) all the documents that are attached with the filled in application form.
Total No. of documents attached
2. Original certificates and mark-sheets are to be produced for verification at the time of admission.

3/4

For office use only

i) Performance in written Test/Interview: Passed/Failed
ii) Documents verification as per Annexure A - Yes/No
Recommendation: The admission of ....................................................................................s/d/o......................................................................
in.................................................................programme for the session.............................................................has been granted/ not granted.
Signature of Admission Co-ordinator
Fee details: Receipt No......................................................amount (Rs.)...........................................................Date.........................................

Authorized signatory
Accounts Section

Check List for documents verification

High school mark sheet (10th Standard)

Attested photo copy

Original

High school certificate (10 Standard)

Attested photo copy

Original

Intermediate mark sheet (12 Standard)

Attested photo copy

Original

Intermediate certificate (12th Standard)

Attested photo copy

Original

B.A./B.Sc./B.Com/BBA/BCA/B. Tech./BDS/ MBBS/Equivalent examinations

Mark Sheet (all semesters/years/consolidated one)

Attested photo copy

Original

B.A./B.Sc./B.Com/BBA/BCA/B. Tech./BDS/MBBS/ Equivalent Degree

Attested photo copy

Original

M.A./M.Sc./M.Com/M.B.A/MCA/M.Tech./Equivalent examinations
Mark Sheet (all semesters/years/consolidated one)

Attested photo copy

Original

M.A./M.Sc./M.Com/M.B.A/MCA/M.Tech./Equivalent Degree

Attested photo copy

Original

Result card of entrance test (if applicable)

Attested photo copy

Original

Original

th

th

Transfer certificate
Migration certificate

Original

Character certificate

Original

Gap year affidavit (if any)

Original

Affidavit on non-judicial stamp paper of Rs. 10 for abiding

university rules and regulations duly signed by student & parent.

Original

Anti-ragging undertaking duly signed by student & parent.

Original

Caste certificate in case of SC/ST/OBC student

Original

Income certificate for parental annual income less than Rs. 1 Lac.

Original

Medical certificate

Original

Attested photo copy

Original

Physically handicapped certificate (if applicable)

Passport sized recent coloured photograph (6 Nos.)

The above documents have been verified and found in order as per the requirement of the University admission process.
Signature & Name of the member of admission committee:1.
2.
Signature of Asstt. Registrar
Date: (Academics)

4/4