ICR FORM FOR ADMISSION AND EXAMINATION
U.P. RAJARSHI TANDON OPEN UNIVERSITY
University Campus
Shantipuram (Sector-F), Phaphamau, Allahabad-211013
ENROLMENT NO. (for Office Use)
DRAFT NO.
FEE AMOUNT
ISSUING BANK
D D M M Y Y Y Y
Photograph
Signature (Within the Box) Subjects offered only for B.A./B.Sc Ist. IInd IIIrd
B.A./B.Sc. Please Tick General Major Job Oriented
1. Candidate's Name (Write in capital letters only)
English
Hindi
2. Father's /Husband Name
English
Hindi
English
Hindi
3. Mother's Name
4. Date of Birth
D D M M Y Y Y Y MALE-M FEMALE-F GEN OBC SC
5. Sex 6. Category
ST
7. Religion : Hindu Muslim Sikh Christian Jain Buddhist Parsi Others
8. Do you belong to Physically Challenged Category : Yes No 9. Territory Rural
Urban
If yes then indicate type of disability a : Orthopaedic b: Visual c: Hearing
10.
11.
Nationality
Complete Mailing Address (Village / Mohalla with House No. and Post Office)
District Name PIN
12.
14.
Phone Number (With STD Code) 13. Mobile Number
Complete Permanent Address (Village / Mohalla with House No. and Post Office)
District Name PIN
Direction to fill the ICR Form:
1. Please read carefully the detailed instructions given in the prospectus/ website before filling this form.
2. No correction shall be allowed after the form is submitted.
3. Incomplete or wrongly filled form is liable to be rejected.
4. Do not STAPLE, FOLD, CLIP this form or make any hole in it.
5. Use BLACK POINT PEN for filling boxes.
6. Fill in the box by CAPITAL LETTERS only.
Form No.
NAME OF THE COURSE

15. Programme Code 16. Programme Name
17. Study Centre Code 18. Medium
Hindi English
19a.. Write Paper Number in the boxes (For Annual System Programme)
I Paper II Paper III Paper IV Paper V Paper VI Paper
VII Paper VII Paper IX Paper XI Paper XI Paper XII Paper
I Paper II Paper III Paper IV Paper V Paper VI Paper
VII Paper VII Paper IX Paper XI Paper XI Paper XII Paper
19b.. Write Paper Number (For Semester System Programme)
20. Academic Qualifications :
Name of Examination Board/University Year Subject
Marks
Max. Obtained
Percentage Div.
High School or
Equivalent
Intermediate
Post Graduation
Others
Graduation
Declaration : The information given in this ICR Form is True and Correct to my knowledge and belief. I fulfill the eligibility conditions required for admission to the academic programme, I have applied for. In case something otherwise becomes known about me the university can cancel my admission and I will not claim refund of the fee deposited. The university can also initiate disciplinary action aginast me as per university rules.
21. Place and Date : ....................................
Checked and Forwarded by Co-ordinator with seal
..............................................
Candidate's Signature
S -
First sem.
Second Sem.