APPLICATION FOR COLLABORATION

ORGANISATION PROFILE

1. Name of the Organization: 2. Year of Establishment: .. 3. Type of Organization: 4. Full Postal Address:... ... District:State: Country:..Pin Code:. 5. Official Communication: Phone No:..Mobile No.: Email:.. 6. Premises Details: 7. Total Carpet Area of Organization (Sq. Ft.) 8. Total Site Area of Organization (Sq. Ft.). 9. Infrastructure Details: Sr. N 1 2 3 4 5 6 7 Other Infrastructure for Training Program Training Rooms Library (Total Books:.) Reading Room/ Conference Room Administrative Area Trainer Room Service Area Toilets etc. Other Units Area (Sq.Ft.) Seating Capacity

COORDINATOR PROFILE
1. Name: 2. Designation: . 3. Sex: .. 4. Qualification: 5. Photo ID Proof:
(Kindly enclose the copy)

DECLARATION

We certify that the particulars furnished above or in the preceding page are true to our best of our knowledge and express our willingness for an inspection to assess the infrastructural facilities, qualified staff etc. We declare that the organization will abide by all the rules and directions of university given from time to time. In case of any information furnished by us is found wrong or incomplete in any regard, we shall be the responsible for any decision taken by university. I hereby confirm that I will regularly visit university website and any information relevant will be received by me from university website. Further, I will never claim any information officially or unofficially in hard copy and email. Therefore, only I will be responsible for all types of consequences, if I dont visit university website.

Date

Specimen Signature of the Proposed Coordinator

Seal & Signature of the Head of the Organization

LIST OF DOCUMENTS

NOTE: The study Centre is also required to submit the following documents/details/information in the Directorate of Distance Education along-with the application form:

Resolution of the Society/Trust for starting the Study Centre List of faculty (bio-data with photograph, nature of appointment, qualification, teaching experience, date of joining at this centre). List of Non-Teaching Staff with designation, responsibilities, qualifications, experience, date of joining at this centre, salary etc. Detail of Time-Table of Theory and Practical (if already running some courses) List and bills of licensed Software/ Hardware (Computers, Printers, Photostat Machine, Fax Machine) List of Equipments in the Laboratories and their bills MOU / Agreements in case there are tie ups for the Laboratories and other facilities Detail and Bills of Library Books, Journals, Magazines and Newspapers. Building documents: Registry (in case of own building)/Rent Deed or Lease Deed (in case on Rent) Proof of Experience of Running Study Centre or in the similar line. Photocopy of Pan Card of the Society/Individual/Study Centre as the case may be. Proof in support of Financial Position Detail of Bank Account showing recent balance in the account. Building Drawings/map with exact measurement in sq feets. List of Proposed Sub Centers (if Applicable) with address. Certificate in case of SC/ST/Ex-serviceman/Physically Handicapped (Minimum 80% handicapped) (if rebate is claimed under these categories). Undertaking (on a non-judicial stamp paper of Rs. 10.00) as per specimen attached.

UNDERTAKING TO BE SUBMITTED BY THE STUDY CENTRES All the Study Centers will be required to submit an Undertaking duly signed by the owner/proprietor/Coordinator/Director of the Study Centre (individually or jointly) as the case may be on a non-judicial stamp paper of Rs. 10/- as per the specimen given below: I, _________________ son of __________________ resident of __________________________ ____________________________and I, ____________________ son of___________________ Resident of______________________________________________ proprietor of Information and Student Support Centre / Study Centre (Code No.___________)/ Sub-Centre named As, _____________________________________ located at_____________________ (Full address and contact Nos.) Hereby affirm and declare: 1. That I have gone through the rules, regulations, guidelines/instructions/norms and standards prescribed by the DDE and/or other regulatory authority of the University for governing Study Centre(s) and I shall abide by all these, notified and to be notified by the University/DDE from time to time. 2. That I will offer only such programmers of the DDE as are allowed, to be run in the centre at the approved location, by the University. 3. That I will enroll students only, as per the admission guidelines issued/to be issued by the DDE from time to time, for the courses which have been allotted to me by the DDE/University. 4. That I will operate only at location(s) which has been approved by the University and in no case I will change the location without the permission of the DDE. 5. That I will charge fee and other dues from the students as per the norms prescribed/notified by the University, from time to time. 6. That I may be held responsible for the acts committed by me or by any of the employees of the Centre which are contrary to the provisions of the University rules/regulations/Act/Statutes etc. 7. I, further declare that I will submit all the required and necessary information or statistics, in the manner and schedule as the University may decide and I shall personally be responsible for the acts of omission and commission on my part or on the part of sub-centers and University will not be liable/responsible towards any commitment(s) made by anyone at study centre.

PROP. /OWNER, STUDY CENTRE (CODE_______) ADDRESS (WITH RUBBER STAMP)

Coordinator/Director/Centre-Head, STUDY CENTRE CENTRE CODE______SUB-CODE_______ ADDRESS WITH RUBBER STAMP