Iuadmissionformnew.pdf

2017224920 Form No.: __________

Admission Application Form (2017-2018) (For Indian/NRI/PIO/OCI Candidates) (Note: Form to be filled in BLOCK LETTERS only) 1. Program Applied for__________________________________________________________ 2. Give branch preference (if applicable) st

Choice_________________________

nd

Choice_________________________

rd

Choice_________________________

1 2 3

3. Campus Applied for

Lucknow

4. Hostel Accommodation required

Paste your latest passport size Colored photograph. Please do not staple. Having 3.5cm x 4.5cm

Shahjahanpur Yes

Candidate's Signature in the box

No

Candidate's Details 5. Name of the Candidate___________________________________________________________________________ (i) Contact Number____________________________________________________________________________ (ii) Email_____________________________________________________________________________________ 6. Gender 7. Date of Birth

M

F

D D

MM

TG

Y Y Y Y

8. Place of Birth__________________________________________

9. Domicile_____________________________

10. Nationality

Indian (includes NRI)

for PIO/OCI/foreign Nationals Others (Specify)________________________________

11. Religion

Hindu

Muslim

Sikh

12. Category

General

OBC

Christian

Others (Specify:_____________)

SC/ST

Parent's Details 13. Father's Name______________________________________________ Contact No.__________________________ 14. Mother's Name_____________________________________________ Contact No._________________________ 15. Email ________________________________________________________________________________________ Address Details 16. Residence Status

City/Town

Village

17. Corresponding Address___________________________________________________________________________ _____________________________________________________________________________________________ City/District________________________________ State _____________________ Pin Code 18. Permanent Address______________________________________________________________________________ City/District________________________________ State _____________________ Pin Code

19. Qualifying Exam status for Admission

Appeared

Passed

(for details of eligibility and qualifying examination, see Page 18-22 of the Prospectus 2017)

20. Qualification Details 12th/ Diploma (if any)

10th

Class

Post Graduation (if any)

Graduation (if any)

Name of Program/Subjects Board/ University Name of College/ Institution & City Year of Passing Roll Number Marks Obtained Maximum Marks Percentage (%)

21. DD Details DD/Pay Order Number____________________Dated_________Amount_______________ Bank Name & Branch________________________________________________________ DD/Pay order of Rs. 1000/- to be made in favour of "Treasurer, Integral University", payable at Lucknow Miscellaneous Information 22. How did you get to know about Integral University Newspaper Internet Radio Friends Relative Univ. Website TV

Magazine Hoardings

Other (Specify) ___________________________________________

23. Have you previously applied for admission to Integral University? Yes No If Yes, Course previously applied for ___________________________________________ Were you selected Yes

No

Declaration I certify that the particulars given by me in this application form are true to the best of my knowledge & belief. I have carefully read the Prospectus of Integral University & agree to abide by the terms & conditions mentioned therein.

________________ Date

________________________ Signature of the Candidate

Documents to be enclosed (As applicable for the opted program) Mark Sheet & Certificate of High School (Std X) or equivalent examination. Mark Sheet & Certificate of Intermediate (Std XII) or equivalent examination. Mark Sheets of all years of Graduation & Degree. (for admission to post-graduate courses only) Referred by (if any) Name____________________________________________ Email Id__________________________________ Employee Code____________________________________ Contact No._______________________________

COMMENTS OF REGISTERING OFFICER (For office use only) Eligible Comments: Checked by:

Provisional

Incomplete

Not Eligible