Jamiya

JAMIA MILLIA ISLAMIA
JAMIA NAGAR, NEW DELHI-110025
Downloaded Form
JMI-WDAF-2012
SIDE 1
APPLICATION FORM FOR ADMISSION-2012-2013 B.Tech./Diploma Engg./M.Tech/M.Sc. Electronics/B.E. (Evening)/Diploma Engg. (Evening)
Please fill in all the entries in CAPITAL LETTERS using a BLACK BALL POINT PEN only.
1. UG Course 2. PG Course 3. Category 4. Branch Preference
For B.Tech/Diploma Engg/ Diploma Engg (Evening) only
Darken 1,2,3,4,5 as per your preference
5. Gender
Male Female
1 2
REGULAR B.Tech Diploma Engg PART TIME B.E. (Civil) B.E. (Electrical) B.E. (Mechanical) B.E. (E/C) B.E. (Computer) Diploma Engg (Evening)
M.Tech. E.Q. Engg.

1 2
1 2 3 4 5
M.Tech. Env. Sc. Engg. M.Tech. EPSM
3 4 5 6 7 8
M.Tech. CIS M.Tech. Mech. Engg. M.Sc. (Electronics)
General Muslims Muslim Women Muslim OBC Muslim Scheduled Tribe Persons with Disability Jamia Kashmiri Migrant
G M
MW MO MT PD
Civil Elect. Mech. E&C Comp.

1 2 3 4 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 1 2 3 1 2 3
6. For M.Tech. Mechanical only

Darken 1, 2, 3 as per your preference Machines Desg. Thermal Prod. & Ind.
J K
J Category is applicable to B.Tech., Diploma Engg. & Diploma Engg.(Evening) applicants only
7. Name as in class 10th certificate (Use CAPITAL LETTERS only. Leave a blank box between First, Middle & Last Names)
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
8. Date of Birth
Day Month Year
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
9. State of Domicile
10. Mobile Number
11. Qualifying Exam. Details (See Information Bulletin & Prospectus for Codes)
Qualifying Exam Code
Board / University
Year of Passing /Appearing

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
Percentage
FORM NUMBER
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0
12. Write name & Complete Mailing Address with BLACK BALL POINT PEN.
Name : S/o or D/o : Address :
14. Photograph
15. Thumb Impression (Male-Left/Female-Right)
District : Tel. No. :
State : PIN Code
13. Applicants Signature

7412
Paste your 4 cm X 5 cm recent photograph (with full name printed on it) within this box. DO NOT STAPLE
SIDE 2
16. Mothers Name (Use CAPITAL LETTERS only. Leave a blank box between First, Middle & Last Names)
17. Educational Qualification Examination X

th
Board / University
School / College
Year
Div.
Agg. %
PCM %
Subjects
XIIth Graduation Others/Diploma 18. Intervening Period i.e. the gap since the qualifying examination passed, if any. 19. Fathers Name 20. Permanent Address DISTRICT STATE EMAIL ADDRESS : 21. Enclosed Demand Draft of Rs. 650/- in favour of Jamia Millia Islamia payable at New Delhi. BANK DEMAND DRAFT No. DATE DRAWN ON (BANK) HOW TO FILL OVALS
Correct Method
PIN CODE
PHONE NO. (With STD Code) :
IMPORTANT INSTRUCTIONS
1. 2. 3. 4. 5 Read the Information Bulletin & Prospectus carefully before filling the form. INCOMPLETE APPLICATIONS IN ANY RESPECT SHALL NOT BE CONSIDERED. DO NOT ATTACH COPIES OF CERTIFICATES/MARK SHEETS WITH THIS FORM. Write Name of the Course on top of the envelope containing the application form. Please refer prospectus for various codes for filling the form.
Wrong Methods
DECLARATION BY THE APPLICANT I, hereby, solemnly declare that the information given in the form is true to the best of my knowledge and belief. I understand that my candidature is subject to the conditions laid down in the prospectus. 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 Father/Guardian .............................................................. Signature of Applicant

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JAMIA MILLIA ISLAMIA

JAMIA NAGAR, NEW DELHI-110025

M.Tech. E.Q. Engg.

M.Tech. Env. Sc. Engg. M.Tech. EPSM

M.Tech. CIS M.Tech. Mech. Engg. M.Sc. (Electronics)

Civil Elect. Mech. E&C Comp.

6. For M.Tech. Mechanical only

10. Mobile Number

Year of Passing /Appearing

15. Thumb Impression (Male-Left/Female-Right)

District : Tel. No. :

State : PIN Code

13. Applicants Signature

17. Educational Qualification Examination X

PHONE NO. (With STD Code) :

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