FMU Research Eligibility Test: Application form

Application Form Form No:
FAKIR MOHAN UNIVERSITY
Space for
attested
Photograph
VYASA VIHAR, NUAPADHI, BALASORE : 756020, ODISHA, INDIA
Application form for FMU Research Eligibility Test
Subject with specialization in which research is to be conducted .........................................
(FOR OFFICE USE ONLY)
Category : General / SC/ST/PH/OBC ............................
Date of Entrance Test ..................................... Result ..........................................................................
DEALING ASST.
1. Name of the Applicant
(in capital letters)
a) Permanent Address CHAIRPERSON, P.G. COUNCIL
:......................................................................................................
:......................................................................................................
......................................................................................................
......................................................................................................
b) Correspondence Address :......................................................................................................
......................................................................................................
......................................................................................................
c) Mob. No
:......................................................................................................
d) E-mail Id.
:......................................................................................................
2. Date of Birth:
Date
Month
Year
(as in H.S.C. Certificate)
(in words ...........................................................................)
3. Sex : Male / Female 4. Marital Status :
5.Nationality ....................
6. Mother Tongue .....................................7. Religion.................................
8. Father’s Name : .........................................................................................................
9. Mother’s Name : .........................................................................................................
FMU | Prospectus | 2013-14
Married / Unmarried
1
10. Academic Qualification :
Degree /
Diploma
Board /
University
Passed /
Appeared
Maximum
Marks
Total Marks
Secured
Division /
Class /
Honours /
Distinction
Year of
Passing
Main / Optional
Subjects
offered
HSC
+2 Arts /
Sc. / Com.
+3 Arts /
Sc. / Com.
M.A /M.Sc./
M.Com / Other
* Attested Copies of Marks sheets / Certificates of all examinations to be enclosed.
11. Mention whether SC/ST/OBC : ...............................................
(Attach Certificate)
12. Bank Draft No. ........................................................... Issuing Bank .............................................................
Date .....................................
Amount ....................................
.DECLARATION
I do hereby declare that the particulars furnished in this form are true to the best of my knowledge and I
shall abide by all rules and regulations framed by the University from time to time. I shall forfeit my candidature
in case of fraud or misrepresentation of facts on my part.
Date ...................................Full Signature of the Applicant
2
FMU | Prospectus | 2013-14