Form No………………

TEERTHANKER MAHAVEER UNIVERSITY

Delhi Road, Moradabad (U.P.)- 244001

Application Form Please paste your

(Session 2010-11) recent coloured
passport size
photograph
here

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 /Diploma in Engineering programs

1. 2. 3. 4.

5. 6. 7. 8.

3. Name of the candidate

(in full & block letters) …………………………………..…………………………………………………………

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

6. Father’s Name ……………………………………………………………………………………………..

7. Mother’s Name …………………………………..…………………………………………………………

8. Category (General/OBC/ST/SC/Others)…………………………………………………………………………..

9. Residence Status (Village/Town/City)………………………………………10. Blood Group.…………..

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 ……………………………..…..

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18. Details of Examination Passed/Appeared
Examination Year of School/ Name of Max. Marks % of Medium of Discipline/
Passing College Board/ Marks Obtained Marks/ Instruction Subjects
Univ. Grade
th
10 (Secondary)

12th (Sr. Secondary)

Graduation
…………………………….
(Pl. specify degree)
Post Graduation
…………………………….
(Pl. specify degree)
Professional Degree
(Pl. specify)……………
Other Qualifications
(If any)……….

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…………………….Cell No…………………………Email ID:…………………………………
Student Contacts:
STD Code………….Tel. No…………………….Cell No…………………………Email ID:………….………………………

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

2010/UPCMET-2010/UPCAT-Dental-2010/CPMT- AIEEE-2010/ Other Recognized Tests
Test……………………………………...Year/Month………………………………….Score………………Rank………..……
(Please attach the certified photocopy of the result)
22. Work Experience (If any): Organization……………………….…………..…………. Experience (yrs.)…………
23. Application fee details:
D.D. No:………………………………………………………….. Date:…………………………………… Amount Rs. 600/-
Name of the Bank:………………………………………………………………………………………………………………………….

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 and also forgo my claim to admission to the University. Further, my candidature for the
examination/admission to the program shall be liable 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.
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 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 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 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

10. Transfer certificate in original from last Institution attended

11. Migration in original from last Board/University attended
12. Character certificate in original from last Institution attended
13. Gap year Affidavit (if any)
14. Affidavit on Non-judicial stamp paper of Rs. 10 for abiding university rules and regulations duly signed
by student & parent.
15. Anti-ragging undertaking duly signed by student & parent.
16. Caste certificate in case of SC/ST/OBC student
17. Parental income certificate (Required only in case of parental annual income less than Rs. 1 Lac)
18. Medical certificate on prescribed performa
19. Physically handicapped certificate (if applicable)
20. 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 submitted for verification at the time of admission.