APPLICATION NO.

:
For office use only

UNIVERSITY OF HYDERABAD
APPLICATION FOR ADMISSION TO DISTANCE EDUCATION PROGRAMME 2012
Read the Prospectus and Instructions carefully before filling up the application form.

D.D. No.

Date

Name of the Bank & Place

Amount

Paste here one recent

Passport size photograph

COURSE APPLIED FOR

CATEGORY
SC

ST

OBC

GENDER

MINORITY

PH

Male

Female

1. Name of the Student (same as in the SSC / Matriculation certificate) in Capital letters
Mr./Ms./Mrs .........................................................................................................................................................................
2. (a)

Fathers Name ............................................................................................................................................................

(b)

Mothers Name ...........................................................................................................................................................

3. (a)

4. a)

Permanent Address:

3 (b)

Address for Correspondence

...............................................................................

......................................................................................

...............................................................................

......................................................................................

PIN ....................... Phone / Mobile No .................

PIN .................. Phone / Mobile No ................................

Email: ...................................................................

Email: ...........................................................................

Date of Birth .................................................................................................................................................................

Date

Month

Year

b)

Identification Marks 1) ........................................

(2) .................................................................................

c)

Nationality ..........................................................

Indian / Foreign .............................................................

If Indian, State of Domicile:........................................................................................................................................ . . .

If foreign national, name of the Country ........................................................................................................................
d)

Sex: Male / Female:

e) Marital Status: Married/Unmarried

If married, name of your spouse: ..................................................................................................................................

5. In case you fail to secure admission to the programme you have applied for, indicate a second choice:
.............................................................................................................................................................................................
6. Annual Income of the family: (If SC/ST/PH) ..........................................................................................................................
Specimen Signature of the student (Sign within the box)
Pin Stamp
Size
Photography

a) Particulars of past academic record (from Bachelors degree onwards)

Examination

University
/ College

Month &
Year of
Passing

Subjects
Studied and
Passed

Maximum
Marks

Marks
Obtained

Percentage

Division

b) Previous and Present Professional Experience

Designation and
nature and job done

Organization / Institution
Total No. of years worked

From
(month & year)

To
(month & year)

DECLARATION BY THE APPLICANT

I hereby declare that all the information furnished by me in this application and the documents I have submitted in support of my
application are true, complete and correct to the best of my knowledge and belief.

Place
Date :
SIGNATURE OF THE CANDIDATE
NOTE:
1.
If the application is downloaded from the website the registration fee is : Rs. 300/2.
If the application is used from printed prospects the registration fee is
: NIL