Price:
Rs 250/-
SIKKIM UNIVERSITY
[A Central University established by an Act of Parliament of India, 2007]
Sl. No…………
Application Form for
PG Diploma in Tea Development and Management, 2012-13
(Last date for submission 25 April 2012)
1. 1. Full Name of the Candidate (as it appears in the School Leaving
Certificate in CAPITAL LETTERS):…………………………………………………………….
2. Date of Birth (dd/mm/yy):
3. A. Father's Name (as it appears in the School Leaving Certificate in CAPITAL LETTERS):
…………………………………………………………………………………………………
B. Mother’s name:…………………………………………………………………………
4. Contact Address:
…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………
………………………… Pincode ……………………
5. Permanent Address:
…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………
………………………… Pincode ……………………
Please paste a
Passport Size colour
photograph duly
attested
2
Residence / Contact Phone No. : ISD code-STD code-Phone No………………………………
Fax (if any) : ISD code-STD code-Fax No………………………………
Mobile Phone No: ………………………………......................
E mail :
6. Gender (please tick): Male Female
7. Nationality: ……………………………………..
8. Category (please tick): :
General
Scheduled Tribe
Other Backward Class: Creamy Layer [ ] Non Creamy Layer [ ]
9. Differently-Abled (with a minimum of 40% disability) (please tick):
Yes No
a. Nature of Disability:……………………………………………………
b. Whether Visually Impaired (please tick):
Yes
No
Note:
a. The University reserves the right to change/cancel any Centre of Examination within India/abroad
without assigning any reason.
10. Academic Record
Name of the
Examination
Year of
passing
Percentage
/CGPA
Name of the
Institution
Board/
University
Subject Combination
Matriculation
or Equivalent
HSE or
Equivalent
Graduation/
College or
Equivalent
Any other
3
11. Present Employment Record ( if employed):
Organisation and
Address
Position Held Period Nature of Duties
12. Details of Bank Demand Draft enclosed towards application processing Fee:
1. Issuing Bank………………………………………
2. Issuing Branch……………………
3. Drawee Branch…………………………………
4. Draft Number:………………………
5. Date …………………………………………
6. Amount ……………………………
DECLARATION BY THE APPLICANT:
I, …………………………………… S/o ………………………………………………… declare that the information furnished by me in the Application Form is true in all respects. In case any entry or information is found to be untrue, this may 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 Prospectus for the programme, I am applying. I shall only appear in the entrance examination after satisfying myself that I do fulfil the same.
If at any stage it is found that I do not fulfill the prescribed eligibility criteria, my admission, if granted,
shall stand cancelled and I shall have no right to admission whatsoever.
Signature of the Applicant
Date………………….
Place…………………
Important Notes:
1. No candidate admitted to a full-time programme of study in the University shall accept or hold any employment paid or otherwise or shall be full time student of any other Institution/University during the course of his/her study at the University except those specifically permitted by the University in accordance with rules.
2. If any information furnished by the candidate in the application form is found to be false, her/ his admission, if granted on the basis of such information, will be liable for cancellation, ipso facto.
3. Incomplete application forms may be rejected without any reference to the candidates. The candidates are, therefore, advised to carefully complete all the relevant columns of the application form.
4. Application forms received after the closing date shall not be entertained.
5. University shall not accept responsibility for any postal delay or irregularity or loss in postal transit.
6. Any dispute with regard to any matter relating to admission shall be subject to the jurisdiction of Sikkim Courts only.