RESIDENTIAL COACHING ACADEMY

CENTRE FOR COACHING & CAREER PLANNING

S.R.K. Hostel Building, Jamia Millia Islamia, New Delhi-110025 Tel. No. 26985492, 26981717 Extn. No. - 4271, 4272, 4274
Roll No:
(To be filled in by the Office) Affix your self attested recent passport size photo

Read the instructions carefully before filling up this form

Application Form for Civil Services (Preliminary-cum-Main) Coaching Program 2013-14
1. Name
(in block letters)

2. Date of Birth:

Date

Month

Year

3. Father's/Husbands Name:

4. Family's Annual Income: 5. Local Address:

Rs.

Pin E-Mail: 6. Permanent Address:

Phone No. Mobile No.

Pin

Phone No. Hindi Urdu

7. Medium:

English

8. Category:
(Tick any one)

Minority

SC

ST

Woman

9. Optional Subject:

10. Details of Examinations Passed: Examinations Passed M.A/M.Sc./M.Com. B.A/B.Sc./B.Com./Engg. Intermediate / Senior Secondary (XII) Matric / Higher Secondary (X) Others Board/University Year of Passing Subjects Division (with % age)

11. Competitive Examinations appeared at: S. No. 1 2 2 4 Name of the Examination Year Roll No. Result

DELCARATION I hereby, solemnly declare that the information given in the form is true to the best of my knowledge and belief. I undertake to accept and abide by the rules of Jamia Millia Islamia and all the decisions of the admission committee and other appropriate university bodies in regard to my admission. I further declare that I am not involved in any criminal case and / or no such case is pending against me in any court of law.

Date:

(Signature of the Candidate)

RESIDENTIAL COACHING ACADEMY

CENTRE FOR COACHING & CAREER PLANNING

S.R.K. Hostel Building, Jamia Millia Islamia, New Delhi-110025 Tel. No. 26985492, 26981717 Extn. No. - 4271, 4272,4274
Affix your self attested recent passport size photo

Hall Ticket (For Centre)

Roll No:
(To be filled in by the Office)

1. Name 2. Father's/Husbands Name: 3. Local Address:

Pin

Phone No.

(Signature of Applicant)

(Signature of Invigilator)

Cut Here RESIDENTIAL COACHING ACADEMY

CENTRE FOR COACHING & CAREER PLANNING

S.R.K. Hostel Building, Jamia Millia Islamia, New Delhi-110025 Tel. No. 26985492, 26981717 Extn. No. - 4271, 4272,4274
Affix your self attested recent passport size photo

Hall Ticket (For Candidate)

Roll No:
(To be filled in by the Office)

1. Name 2. Father's/Husbands Name: 3. Local Address:

Pin

Phone No.

(Signature of Applicant)

(Signature of Invigilator)

ACKNOWLEDGMENT SLIP
Received an application form from (candidates name) for admission to Civil Services (Preliminary-cum-Main) Coaching Program 2013-14

Date..

(Signature of receiving Official)

INSTRUCTIONS
1. All the particulars must be filled in by the candidate in Block Letters. 2. All the particulars must be filled in by the candidate in his/her own hand writing. 3. Candidate falling under more than one category should choose any one category for consideration and tick the same in the form. The woman candidate should also tick the woman category. 4. Submission of Application Form will be no basis for claiming admission. 5. Do not attach copies of mark sheets, certificates etc. with this form. 6. The self-attested legible copies of the following documents shall be submitted at the time of interview and admission. All Educational Certificates. Permanent Address Proof. Category/Caste Certificate (if any). Annual Family Income Certificate. Four recent passport size photographs. Admit card of last competitive examination (if applicable)

7. Incomplete Application form will not be considered.

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