Application Form Form No.
Space for
attested
FAKIR MOHAN UNIVERSITY Photograph
VYASA VIHAR, NUAPADHI, BALASORE - 756 089
Application form for admission into ……………………………………. (Course Applying for)
(FOR OFFICE USE ONLY)
Index No. Category: General / SC/ST/PWD/OBC/Ex-Serviceman
Class Roll No Date of Admission …………………………………………...
ENDORSED
HEAD OF THE DEPARTMENT/ CHAIRMAN P.G. COUNCIL
COURSE CO-ORDINATOR
1. Name of the Applicant ……………………………………………………………………………….
(in capital letters)
a) Permanent Address: ...…………………………………………………………………………..
…………………………………………………………………………….
………………………..…………………………………………………..
b) Correspondence Address:…………………………………………………………………………...
…………………………………………………………………………….
………………………..…………………………………………………..
c) Mobile Number: ……………………………………………………………………………………
d) Home Mobile Number…………………………………………………………………………….
e) Email ID……………………………………………………………………………………………….
2. Date of Birth …………………………………………………………. (as in H.S.C. Certificate)
Date Month Year
(in words……………………………………………………………………………………………………)
3. Sex: Male / Female/Transgender 4. Marital Status: Married / Unmarried
5. Nationality…………………………. 6. Mother Tongue…………………………..
7. Religion …………………………….. 8. Aadhar Card No…………………………
9. Blood Group :……………………. 10. Do you Want to Apply for Hostel? (Y/N)
11. Father's Name :…………………………………………………………………………………………...
12. Mother's Name:……………………………………………………………………………………………
13. Guardian's Name:………………………………………………………………………………………..
(if other than Father / Mother)
14. Occupation of Father/ Guardian……………………………….Mother………………………….
15. University Registration No.:……………………………………………………………………………
( For students who have passed from this University)
16. Academic Qualification
Board / Division/ Main/
Degree / University Maximum Class/ Year of Optional
Total Marks
Diploma passed/ Marks Honours/ Passing Subject
Appeared Distinction Offered
HSC
+2 Arts/
Sci./ Com.
+3 Arts/
Sci./ Com
P.G. Any
other
Degree
Attested Copies of Mark sheets/ Certificates of all examinations to be endorsed
17. Mention whether : SC/ST/OBC/PWD/EX-SERVISEMENT
(Attested Certificate)
18. Mention if Physically Handicapped with
40% Disability (Attested Certificate) : YES / NO
19. Are you currently employed: YES/ NO
20. Bank Draft No……………………………………………… Date:……………………………….
Issuing Bank……………………………………………….. Amount:…………………………..
DECLARATION
I do hereby that particulars furnished in the 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 fasts on my
part.
Date: Full Signature of the Applicant
UNDERTAKING
BY A STUDENT FOR ADMISSION INTO POST-GRADUATE DEPARTMENTS OF
FAKIR MOHAN UNIVERSITY
Vyasa Vihar, Nuapadhi, Balasore - 756089
I do hereby undertake that in the event of my admission, I shall abide by the rules of
University and the Hostels attached to it. I also hereby undertake that in case of any
indiscipline / disobedience or violation on my part of the rules laid down by the University
authority empowered by them in this regard or should my conduct in the University be found
not satisfactory my name will automatically be removed from the University register. I also
undertake to abide by the decision regarding examination fixed by the authorities of the
University.
Countersigned
Signature of Father / Mother / Legal Guardian Full Signature of the Applicant
....................................................................
FAKIR MOHAN UNIVERSITY
VYASA VIHAR, BALASORE, OD1SHA Space for
attested
ADMIT CARD FOR ENTRANCE TEST Photograph
2020-21
Name of the Department / Programme ……………………………………Index No. …………...
Name of the Candidate ……………………………………………………………………………………
Full Signature of the Candidate …………………………………………………………………………
You are allowed to appear at the P.G./M.Phil. Entrance test at F.M. University campus as
per the following schedule. Any malpractice or misconduct at the entrance examination
will disqualify you from selection. You are required to produce this admit card at the time
of written test.
Date of Entrance Test : Head /Course Coordinator
Time of Entrance Test : Department / Programme………………..
