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University of Hydrabad Entrance Examination Form - 2013

1. Application Number
2. Name of the candidate 3. Date of Birth 5. Nationality 7. Category : General

: 1317869
: S BHASKAR : 19-07-1992 : Indian 4. Sex : Male 6. State of Domicile : Orissa 9. Whether PH : NO PH Type : -10. Blood Group : B +ve 13. Dist in Sports : -16. Subject : Physics

8. Whether DP : NO RA

11. Position of Qualifying Exam : 14. Centre 17. Choices

12. Percentage of Marks : -15. Course : M.Sc.

: Bhubaneswar : --

18. For M.Tech - GATE Hall Ticket No : --

Subject

: --

GATE Score

: --

19. For M.Phil./Ph.D.- Have you Qualified : JRF/ NBHM/ICMR/ICAR/DBT / RGNF / MANF /DST INSPIRE : -Are you seeking exemption from appearing in the written test on the basis above JRF : -Whether applying for Regular, Part time or External Registration to Ph.D : -20. For 5-year Integrated M.A./M.Sc courses Are you a Scholar of (/Science Olympaid/ IIT JEE Ranker / I ranker at +2 Boards) : -Do you belong to any of the backward district: -If yes, Place of Birth: -District : -State: -Medium of Instruction in Intermediate : 21. Name of the Father 22. Name of the Mother : S RAVANA : S PAPAMA : 30000 District : -: -Distance from Hyderabad State : -: --

23. Annual Income of the Parents/Guardian (Rs.) 24. Native Place : --

25. Nearest Railway Station 26. Address Permanent Address: AT-CHARAMPA

Present Mailing Address: AT-CHARAMPA PO-CHARAMPA VIA-BARAL POKHARI BHADRAK 756101 ORISSA

PO-CHARAMPA VIA-BARAL POKHARI BHADRAK 756101 ORISSA e-Mail Id : sbhaskar51@yahoo.com

Mobile No

: 9338681291

Mode of Payment DD/Challan Journal No. Bank

: Demand Draft : 219008 Branch : BHADRAK BRANCH Date : 09-01-2013 Amount : 350.00

: STATE BANK OF INDIA

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27. Past Academic Record Examination Passed Name of the Univ Subject Studied and Month & Year of / Course HSC SCIENCE SCIENCE / Board BSE ODISHA CHSE ODISHA FM UNIVERSITY 28. For Statistical Purpose only Whether you are interested to enroll in NSS : YES Do you belong to LBC : NO Religion : hindu Do you belong to any minority Community : NO Do you belong to Kashmir Migrant : NO Are you a single girl child of your family : NO How do you know about this Notification : website UNIVERSITY WEBSITE 29.If applying for M.Phil., M.Tech., or Ph.D. programmes a) Mention areas of research interests in order of preference: 1)----------------------------- 2)----------------------------- 3)----------------------------b) Give details of publications & research work carried out, if any ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------c) Have you qualified/appeared in the UGC/CSIR National level test for JRF ? : If yes, give the following details : Name of the Exam: -------------------------------------- Qualified : Roll No : ---------------------------- Subject : ---------------------------- Year & Date of examination : ---------------------------If holding the Fellowship, the date from which it is held : Date : -------------------- Month : -------------------- Year : -------------------d) Do you possess M.Phil/M.Tech degree? : Did you avail the exemption on an earlier occasion?: Note : Candidates with UGC-NET for lectureship alone and possessing M.Phil./M. Tech. Degree are not exempted from the written test 30. Present or previous employment, if any Organisation & Address 31. Do you require Hostel Accommodation ? : YES 32. Were you ever subjected to a disciplinary action by any authority ? : NO If yes, give details : 33. Any other relevant information : Position Held From - To Nature of Duties Passed ALL SUBJECT ELECT PHY HONS MATH Oct-2012 CHEM Passing Jun-2008 Result Max Marks 800 600 1200 Min Marks for Pass NA NA NA Marks Obtained 475 442 800 % of Marks 59.60 73.60 66.67 Division / Class 2ND 1ST 1ST

PHY CHEM MATH May-2010

DECLARATION BY THE APPLICANT: I hereby declare that all the information furnished by me in this application and in the documents I have submitted in support of my application are true, complete and correct. In case any information in this application is

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found to be false or incorrect at any time (during or after completion of the course), this shall entail automatic cancellation of my admission, if granted, cancellation of the degree if awarded , besides rendering me liable to such action as the University may deem fit. In the event of any medical or other emergency, my parent/s or Guardian may be contacted at the address given below

Signature of the Candidate DECLARATION BY THE FATHER/MOTHER/GUARDIAN : My daughter/son/ward Mr./Ms S BHASKAR is applying for admission to the University. In case of her/his admission to the University, I shall be responsible for payment of all her/his fees and other charges including any emergency, medical or other expenses incurred by the University. In case any information in this application is found to be false or incorrect at any time (during or after completion of the course), this shall entail automatic cancellation of my daughters/sons /wards admission, if granted, cancellation of the degree if awarded, besides rendering her/him liable to such action as the University may deem fit. I will also be responsible for her/his good conduct and behaviour during the period of her/his stay in the University. Further, I may be contacted in the event of any emergency as determined by the University and I hereby promise that I will make myself present before the University authority at my own cost whenever the University require my presence.

Signature of the parent / Guardian Place : Date : Full Name :----------------------------------------Relationship with the applicant :-----------------------Telephone numbers (if any) :------------------------Affix your recent passport size colour photograph duly attested by a Gezetted officer.

Enclosures: 1. Bank Challan (UOH copy) / DD 2. 3. 4.