CHEBROLU HANUMAIAH INSTITUTE OF

Application No:______ APPLICATION FORM FOR ADMISSION INTO FIRST YEAR Pharm.D COURSE UNDER 30% CATEGORY “B” SEATS (MANAGEMENT QUOTA ) FOR THE ACADEMIC YEAR 2012­2013 IN CHEBROLU HANUMAIAH INSTITUTE OF PHARMACEUTICAL SCIENCES (Sponsored by Nagarjuna Education Society) (Affiliated to Acharya Nagarjuna University ­ Approved by AICTE & PCI) CHANDRAMOULIPURAM :: CHOWDAVARAM :: GUNTUR­522 019 Ph.Nos. 7382008494, (0863) 2232505 (City Office) :: Fax: 0863­2350343, 2288274 (To be filled by the candidate in English in his/her hand­writing. Study the prospectus before filling in the application) Wherever necessary attested copies of certificates are to be enclosed as proof. Ex: Date of Birth, Schooling etc. Affix passport size photograph 1. Course applied for: 6­Year Pharm.D Course 2. NAME OF THE CANDIDATE: (in full and in block letters as entered in S.S.C. or equivalent certificate) 3. Father’s name: (in full and in block letters) 4. (a) Complete Postal Address for communication (in block letters) PIN (b) Permanent Address with PIN code (in block letters) PIN 5. Particulars of Parent/Guardian: (Guardian, only if father is not alive) Name: Relationship: Occupation: Office: Address: Phones: Resi: Mobile: Local Guardian if any, Address: Office: Phones: Resi: Mobile: 6. CANDIDATE’S Sex: M Date of birth: Marital Status F Married Single (As per School Records) (Christian Era) Nationality: Do you belong to Andhra Pradesh State YES NO
7. Identification marks of candidate as given in School records: 8. Particulars of Qualifying examination. (Attach copies of marks) a) Intermediate examination or equivalent: b) Optional / Chosen subjects: Marks secured/total: % of marks: Grade/Division: Marks in Group & % of marks 9. Furnish the particulars of schooling for a period of three consecutive Academic years ending with the qualifying examination (copies of bonafide study certificates should be attached as proof). Sl. No. Class Studied 1. SSC 2. Intermediate / equivalent 3. Diploma in Pharmacy Academic year(s) (if you did not study in any year, state so, with reasons in the remarks column) Name of the institution in which studied and the district in which it is situated. Remarks 10. EAMCET­2012 Rank, if any DECLARATION BY THE CANDIDATE I am aware that the allotment of admission is provisional and subject to ratification by Government. I declare that all the foregoing statements made in this application are true to the best of my knowledge. I accept that any statement made in this application if found incorrect on scrutiny, will render the application liable for rejection and admission, if granted on basis of such incorrect information, will stand cancelled. I sincerely assure that, if admitted, I will strictly adhere to the rules and regulations that may be adopted by the University/Government from time to time and will abide by the rules of discipline of the college. I agree to abide by the decisions of the Principal of the college for any misconduct or misbehaviour or breach of rules by me during the entire period of my study. Date: Place: Signature of the Candidate DECLARATION BY THE PARENT OR GUARDIAN OF THE CANDIDATE I certify that the particulars furnished above by my son/daughter/ward are true. I accept that any statement made in the application, if found incorrect on scrutiny, will render the application of my son/daughter/ward liable for rejection and the admission, if granted on the basis of such incorrect information will stand cancelled. I shall be responsible for his/her conduct, good behaviour and compliance with the rules in force from time to time during the entire period of his/her study. I promise to abide by any decision taken by the Principal for any misconduct or misbehaviour or breach of rules by my son/daughter/ward. I hereby declare that I agree to meet the expenses in the college of my son/daughter/ward during the entire period of his/her course. I shall also hold myself responsible and compensate for any damages caused by my son/daughter/ward to the college. Date: Station: Signature of Parent or Guardian ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ FOR OFFICE USE ONLY
UNDERTAKING From: To The Principal, Chebrolu Hanumaiah Institute Pharmaceutical Sciences, Chandramoulipuram, Chowdavaram, GUNTUR­522 019 I, of …………………………………………………………………………………………………. S/o, D/o ……………….…………………………………….. request that I may be admitted into 1 st Year Pharm.D in Chebrolu Hanumaiah Institute of Pharmaceutical Sciences during the academic year 2012­13 under 30% ‘B’ category seats (Management Quota). I shall abide by the Court decisions/Acharya Nagarjuna University Orders/Government Orders etc. concerning my admission and I shall not hold the Chebrolu Hanumaiah Institute of Pharmaceutical Sciences responsible if the Court Orders/Acharya Nagarjuna University Orders/Government Orders held my admission invalid. Signature of the candidate Date: Signature of the parent
CHECK LIST Name of the Student : Branch: PHARM.D DETAILS OF ORIGINAL CERTIFICATES SUBMITTED: 1) EAMCET­2012 Hall Ticket & Rank Card, if appeared. YES / NO 2) S.S.C.marks memorandum. YES / NO 3) Intermediate marks memorandum. YES / NO 4) Transfer Certificate. YES / NO 5) Conduct Certificate. YES / NO 6) Study certificate for last seven years i.e. from 6 th class to Intermediate. YES / NO 7) Residence certificate for the last seven years. YES / NO 8) Passport size photos – 5 Nos. YES / NO 9) One set of Xerox copies for all the above original certificates. YES / NO Signature of the student Verifying Officer Signature of the Parent / Guardian Administrative Officer Principal Undertaking to be executed by Mr./Ms.______________________________________________
S/o, D/o ____________________________________________________ seeking admission into I Year Pharm.D Course in Chebrolu Hanumaiah Institute of Pharmaceutical Sciences. I _____________________________________ S/o, D/o________________________________ Native _________________________________ Mandal ____________________________ District ___________________________________________ hereby give the following undertaking/agreement. At the time of admission into Pharm.D Degree Course in Chebrolu Hanumaiah Institute of Pharmaceutical Sciences, Chowdavaram. I was fully explained by the Principal that in case I leave the above institution on my own accord on Transfer Certificate before the completion of four years, I will be required to pay the balance of Tuition Fee due from me at the rate of ______________or the fee fixed by the Government of AP for the unexpired portion of the Pharmacy Degree Course of four years duration. Having fully aware of the above condition I am joining the 6­year Pharm.D Degree Course in the above institution. I further undertake that I will not seek for the waiver of the condition stipulated above in any court of law and further agreed that I will pay the balance fees as stated above for the unexpired portion of the 6­year course, in case I leave the institution on my own accord and if I fail to pay the same, the college authorities shall recover the same from my personal properties. Signature of the candidate Guarantor Date: Signature of Parent/Guardian
DECLARATION BY THE STUDENT 01. Name of the student : 02. Father’s Name : 03. Address for communication (IN BLOCK LETTERS) : 04. (a) Sex: (b) Category (Put mark on the concerned) OC BC SC A B C D E 05. (a) Rank: (b) Course: ST NCC PH Ex­servicemen Merit/Management Quota seat 06. Date of admission: All the information furnished above is true. I am aware of the promotional rules of Pharm.D in Acharya Nagarjuna University. I assure that I shall not indulge in ragging in any manner and I am aware of the punishments in Prohibition of Ragging Act. I shall abide by the discipline and conduct rules and practices adopted by the college from time to time and shall not appeal against any punishment imposed by the college for violation of norms of conduct & discipline. In second week of every month, I shall meet our in­charge of attendance and marks to collect my copy of attendance and/or marks particulars and to sign on three copies of the same. Also, I ensure that correct mailing address of our parents is furnished in records from time to time by informing the change, if any. Place : Date : For Office use only Roll No: Section:
Signature of the student DECLARATION BY THE PARENT / GUARDIAN 01. Name of the student : 02. Father’s name : 03. Address for communication with PIN Code (IN BLOCK LETTERS) : All the information furnished above is correct. I am informed that, as per Acharya Nagarjuna University rules, securing 75% of attendance and scoring 50% of internal marks is compulsory for appearing for University Examinations as otherwise the student will be detained in the same year. Further, I am informed that a letter containing particulars of attendance and/or marks will be dispatched to us in every month. Hence, I shall take necessary measures to improve the performance of my son/daughter/ward. Also, I assure that I shall be contact with the concerned attendance in­charge in case of non­receipt of such letters. Further, I declare that it is my responsibility to inform any change in my mailing address, if any, and I shall co­operate with the administration to maintain discipline. I am aware of the promotional rules of Pharm.D in Acharya Nagarjuna University. I assure that I shall take necessary measures so that my son/daughter/ward will not indulge in ragging in any manner and I am aware of the punishments in Prohibition of Ragging Act. I shall not appeal against any punishment imposed by the college on my son/daughter/ward for violation of norms of conduct and discipline that are adopted by the college from time to time. Place : Date : Signature of the Parent/Guardian
CHEBROLU HANUMAIAH INSTITUTE OF PHARMACEUTICAL SCIENCES CHANDRAMOULIPURAM :: CHOWDAVARAM­522 019 PHARM.D COURSE ADMISSIONS 2012­2013 For Office use Only Adm.No.______________________ Regd.No. _____________________ Course: ______________________ Roll No._______________________ ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ Name of the candidate : ________________________________________________ Father’s name : _________________________________________________ Intermediate : Marks___________________ H.T.No._________________ EAMCET­2012 : Rank______________________ H.T.No.________________ Date of birth :___________________________ Identification marks : I) _______________________________________________ ii) _______________________________________________ Father’s occupation & Income(per annum) :_________________________________________________ Whether belongs : SC/ST/BC­A/B/C/D/E Admitted under category Branch admitted Amount of fee paid (___________________) : ___________________________ : ___________________________ : ___________________________ Residential Address: a) Permanent (b) For correspondence _________________________________ ______________________________________ _________________________________ ______________________________________ _________________________________ ______________________________________ _________________________________ ______________________________________ _________________________________ ______________________________________ PIN:_____________ Phone:__________ PIN: ______________ Phone: _____________ Native place for issuing Railway Concession: _____________________________________ Affix recent passport size photograph
(Signature of the candidate) DT: _______________ Undertaking to be executed by Mr./Ms.______________________________________________ S/o, D/o ____________________________________________________ seeking admission into I Year Pharm.D Course in Chebrolu Hanumaiah Institute of Pharmaceutical Sciences. I _____________________________________ S/o, D/o________________________________ Native _________________________________ Mandal ____________________________ District ___________________________________________ hereby give the following undertaking/agreement. At the time of admission into Pharm.D Degree Course in Chebrolu Hanumaiah Institute of Pharmaceutical Sciences, Chowdavaram. I was fully explained by the Principal that in case I leave the above institution on my own accord on Transfer Certificate before the completion of four years, I will be required to pay the balance of Tuition Fee due from me at the rate of ______________or the fee fixed by the Government of AP for the unexpired portion of the Pharmacy Degree Course of six years duration. Having fully aware of the above condition I am joining the 6­year Pharm.D Degree Course in the above institution. I further undertake that I will not seek for the waiver of the condition stipulated above in any court of law and further agreed that I will pay the balance fees as stated above for the unexpired portion of the 6­year course, in case I leave the institution on my own accord and if I fail to pay the same, the college authorities shall recover the same from my personal properties. Signature of the candidate Guarantor Date: Signature of Parent/Guardian
DECLARATION BY THE STUDENT 01. Name of the student : 02. Father’s Name : 03. Address for communication (IN BLOCK LETTERS) : 04. (a) Sex: (b) Category (Put mark on the concerned) OC BC SC A B C D E 05. (a) Rank: ST (b) Course: NCC PH Ex­servicemen Merit/Management Quota seat 06. Date of admission: All the information furnished above is true. I am aware of the promotional rules of Pharm.D in Acharya Nagarjuna University. I assure that I shall not indulge in ragging in any manner and I am aware of the punishments in Prohibition of Ragging Act. I shall abide by the discipline and conduct rules and practices adopted by the college from time to time and shall not appeal against any punishment imposed by the college for violation of norms of conduct & discipline. In second week of every month, I shall meet our in­charge of attendance and marks to collect my copy of attendance and/or marks particulars and to sign on three copies of the same. Also, I ensure that correct mailing address of our parents is furnished in records from time to time by informing the change, if any. Place : Date : For Office use only Roll No: Section:
Signature of the student DECLARATION BY THE PARENT / GUARDIAN 01. Name of the student 02. Father’s name : : 03. Address for communication with PIN Code (IN BLOCK LETTERS) : All the information furnished above is correct. I am informed that, as per Acharya Nagarjuna University rules, securing 75% of attendance and scoring 50% of internal marks is compulsory for appearing for University Examinations as otherwise the student will be detained in the same year. Further, I am informed that a letter containing particulars of attendance and/or marks will be dispatched to us in every month. Hence, I shall take necessary measures to improve the performance of my son/daughter/ward. Also, I assure that I shall be contact with the concerned attendance in­charge in case of non­receipt of such letters. Further, I declare that it is my responsibility to inform any change in my mailing address, if any, and I shall co­operate with the administration to maintain discipline. I am aware of the promotional rules of Pharm.D in Acharya Nagarjuna University. I assure that I shall take necessary measures so that my son/daughter/ward will not indulge in ragging in any manner and I am aware of the punishments in Prohibition of Ragging Act. I shall not appeal against any punishment imposed by the college on my son/daughter/ward for violation of norms of conduct and discipline that are adopted by the college from time to time. Place : Date : Signature of the Parent/Guardian