MADHYA PRADESH BHOJ (OPEN) UNIVERSITY
BHOPAL
Admission Form for the year 2009-10
INSTRUCTIONS :
(i) Before filling up the Application Fonn, Please read instructions carefully.
(ii) Use the BLACK BALL Pen and CAPITAL LETTERS for filling this form.
(iii) Do not stapple the photograph.
Admission Category : FRESII/REAPPEAR/ATKT
Ragging is completely Prchibited and is Punishable.
Detdi of Fee (plcere ettach one copy of chelhn)
Union Bank Branch Place Union Bank Branch Code
ROLL/REG. No. Regional / IIMM Centre Name Regional / IIMM Centre Code
Course Name Course Code Subj ecVSpecialization Part I/IV[VPreviouVFinal
Fee Amount (Rs.) Challan Date
Name of the Crndidate In
Addrers of the Candidate(VYrlte your complcte malllngAddress In Black ink includlng namc In CAPITAL LETTERS
Name & Address
State
Pin Code
PhoneNo. with STD Code
Mobile No.
Passport size
Photograph
(Pleasep aste)
Signature of the Student
emetlAddrerc
Generat informatlon (pleasc tick (/; correct merk in given bor)
A. Dateof Blrth
B. Gender

Date of E. Arg4- F. Social Status G .Mertiel Strtus
ocCourseN
ame
Name of Theory Papers
I
2.
3.
4.
6
7
8
If appearingin Part II/m & Final Examinetiong ived eteilso f marks obtsinedl n PreviousE xaminations
Particulars of the present Examinetion in whlch you intend to eppesr
(Note : Change of Subjects is not allowed tn IIIIII Yeer of graduation)
Course Marks Obtained Max. Marks. Result Year
Signature
Regional Director/
CourseCmrdinatorllMM
Place
Date
I hereb y Declaret hat:
Decleration by the candidate
L Thea bovein formationi s trueI haven ot beend ebarredfr om appearingin thee xaminationfo r useo f unfairm censb y anyU nivcnity.
I am alsoa ppearinign .................
appearingin anyo therE xamination.
2.I amawarethatintheeventofanfayl sei nformationbeinggivenbmy ei nthisa pplicationmyc andidaturcmabye cancellcdandfccs
be forfeitaed
3.I Certifyt hatthea boves tatemenhtsa veb eenfi lled in bymea ndt hatt hee ntriesm adea rec orrect!oth ebestofmyk nowledge.
Signatureo fapplicant
Fonvrrdlng Certllicrte
Name....
I here by certify that
o f . . . . . . . . . . . . . ' . ' . . . . . . . . . ' ; . . . ' ' . ' . . . . . . i s a admited of this Regional Centre He / She has
to appearin th
after fulfilling all the conditions laid down in the information brochure.
Signatur€
Dircctor (A&E)
Enclosures:
(a)P leasee ncloseac opychallan/receipofthea mountofFeementioneadg ainstthecoune..............
(Fee detail enclosed) forwhich you are applyrng. Mode ofPaymerit-Through challan, payable to the Registrar, M.P. Bhoj (Open)
University, Bhopal.
(b)AtteStedc opieso fthe Mark-Sheetof(llr2), Graduatea ndP ostG raduateExasrinations.
(b) Certificate ofbeing a SC/ST/OBC(issued bi CompetentAuthority)
(d)Fee Relaxation formdully sigrred alongwith domicle certificarc and income certificate ofthe cunentyear.
Note :- Incompletea pplication,w ithout mark sheetsa ndo therr elevantd ocumenBw ill not be considered.
Whethery our are erpelledirertr:lcetfcr om eny cducatlondI ncdtuteo f convlctedb y e court of law of lf eny
Cese is Pendlng ageinrt you ln t Court of Law? If so gfve deteils
36