Application form
Central University of Orissa
Koraput
Application Form for Entrance Examination – 2013-14
1. NAME OF THE CANDIDATE AS IT APPEARS IN THE SCHOOL LEAVING CERTIFICATE (IN CAPITAL LETTERS)
12. Details of Bank Draft / Challan enclosed towards Entrance Examination Fee
13. Father’s Name (IN BLOCK LETTERS)
Mother’s Name (IN BLOCK LETTERS)
14. YOUR COMPLETE POSTAL ADDRESS INCLUDING YOUR FULL NAME 15. PHOTOGRAPH
(WRITE IN CAPITAL LETTERS, USE BALL POINT PEN WITH BLACK INK).
To be submitted at the time of Registration for Examination
APPLICATION FORM INCOMPLETE IN ANY RESPECT SHALL NOT BE CONSIDERED
Indian
Foreigner,
country,
if foreign National
……………………
4. Nationality
General
S.C.
S.T.
O.B.C. (Non Creamy Layer)
Foreign National
5. CATEGORY
Yes No
6. Are You Blind?
Name………………………………………………
Address…………………………………………………..………………………………………….………………..…………………………………………………………………………………………………………………………………………………………Pincode:
Paste here firmly your recent colour photograph of good quality
(Size 3.5 CM x 4.5 CM)
Do not staple
Application No.
Gender Female
3. Gender
7. Do you belong to Physically Handicapped
Yes
No
8. STATE OF DOMICILE
D.D. / I.D NUMBER
DATE OF DEMAND DRAFT/ CHALLAN
D D M M Y Y
Day Month Year
2. Date of Birth
9. Programme for study
M.A.
/M.Sc.
10. Choice of Subject
Subject Name / Code
AMOUNT
11. Entrance Exam Center Code
Central University of Orissa, Koraput
2
16. 17. Academic Records: Note : Taken into account only marks in the subjects which are counted for awarding class/division.
Examination passed
Year of passing and Division
% of Marks OGPA or Grade
Name of School/College/Institution and District in which situated
Name of Board/University
Subject/Papers Offered
High School / Matriculation / 10th Class
Senior School Certificate (10+2) Intermediate or equivalent
B.A./B.A.(Hons.)/B.Com /B.Com (Hons.)/B.Sc./ B.Sc.(Hons.)/B.Tech/B.E. /M.B.B.S. Any other Graduate Degree…………………… Aggregate
M.A./M.Sc./M.C.A Any other P.G. Degree Aggregate
Any other examination please specify…………………………………………………………………
*Strike off the Name of Examination which is not applicable. 18. Details of present employment
Organization & Address
Position held
Period
Nature of Duties
19. Name of the Parent/Guardian/Legal guardian and Address:___________________________________________________________________ __________________________________ 20. Annual family income 21. Parent’s/Guardian’s Occupation
Signature (within Box) in running hand using black ball point pen only
(Do not sign in capitals)

Do not get the photograph attested
Agriculture Public Govt. Service
Business Private Service
Medical Defense Service
Engineering Teaching/Research
Law Practice Others
Less than Rs. 50, 000/- per year
Between Rs. 50, 000/- to Rs. 1,00,000/- per year
Between Rs. 1,00,000/- to Rs. 2,00,000/- per year
Above Rs. 2,00,000/- per year
3
21. Whether need a seat in the hostel? Yes /No DECLARATION BY THE APPLICANT
I declare that the information furnished by me in the Application Form is true in all respects and incase any entry or information is found to be false, this shall entail automatic cancellation of my admission besides rendering me liable to such action as the University may deem proper. I hereby undertake that I have carefully gone through the eligibility conditions prescribed in the website www.cuo.ac.in for the programme I am applying for and shall appear in the entrance examination after satisfying myself that I do fulfill the same. If at any stage it is found that I do not fulfill the minimum prescribed eligibility criteria, my admission, if granted, shall stand cancelled and I shall have no right to admission whatsoever. Further I undertake that I will be abided by all rules and regulations prescribed by the University authorities. Signature of the Applicant Date……………… Telephone No. with STD Code ……………………………….. Fax No……………………… Place ……………………………… Mobile No. ………………………………..….. E-Mail………………………………… Note: Student can appear in any two programmes offered by Central University of Orissa, Koraput. Separate applications/ fees has to be submitted at the time of registration for entrance examination if the student wishes to appear in two programmes.