APPLICATION FOR STUDY CENTRE

Details of the institution: Name of the Institute Name of Parent Body (Trust/Society/etc.) Year of Establishment

Registration No.

District & State

Head of the Institution Email ID Website Telephone Number Mobile Number

Name

Designation

Details of the Management: Name Brief Address Member 1 Designation Email ID Phone No. Name Brief Address Member 2 Designation Email ID Phone No.

Name Brief Address Member 3 Designation Email ID Phone No. Name Brief Address Member 4 Designation Email ID Phone No. Name Brief Address Member 5 Designation Email ID Phone No.

Are you associated with and University/Institution for Distance or Regular Education? If so, Give details. Name of the Institution Name of the University/Institu tion Associated Since (YYYY) Mode (Distance/R egular) Programmes being offered No. of students

S. No.

About the Proposed Institute: 2

Head Reg. Address (with PIN Code) Address for correspondence (with PIN Code) Email ID Telephone Number Mobile Number Name of nearest prime location/Road of the town/city Parking Space Available Is property Commercial or Residential Is property Owned or Rented Total Carpet Area (In Sq. Ft.)

Particular

Connectivity: Nearest Airport (Name & Distance) Nearest Railway Station (Name & Distance) Nearest Bus Stand (Name & Distance)

Faculty & Staff Details S. No. Name Department Designation Qualification Exp In Yrs Full Time / Part Time

*Departments: Academic, Administration, Accounts, Database, Support Details of Project Coordinator Name Qualification Exp (In Yrs) Appointed Since Mobile No.

Email Address

Library Details S. No. 1 2 3 4 5 Reference Book Text & Subject Books Journals Subscribed Newspaper Subscribed Course CDs Category Count

Date:..

Authorized Signatory (with Name)

PHOTOGRAPHS TO BE PASTED:

SPACE FOR AFFIXING FRONT PHOTOGRAPH OF THE INSTITUTION

SPACE FOR AFFIXING PHOTOGRAPH SHOWING THE LOCALITY OF THE INSTITUTION

SPACE FOR AFFIXING

RECEPTION AREA OF THE INSTITUTION

SPACE FOR AFFIXING DIRECTOR OFFICE OF THE INSTITUTION

SPACE FOR AFFIXING

COUNSELLING AREA OF THE INSTITUTION

SPACE FOR AFFIXING LECTURE ROOM OF THE INSTITUTION

SPACE FOR AFFIXING COMPUTER LAB OF THE INSTITUTION

SPACE FOR AFFIXING LIBRARY OF THE INSTITUTION

Checklist for Submission of Application Form

S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Particulars Registration Certificate & Memorandum of Society, Trust or Company Resolution of Society, Trust or Company for Tying Up with Address proof of Institution (Lease Deed/Rent Agreement/Sale Deed/Ownership Documents) Audited Balance Sheet of previous two years PAN Number of the Institution Floor Plan/Layout Map of the Institution Photograph of the Institution front Building, Reception, Directors office, Counselling, Classrooms, Lab, Library. Photo ID Proof of Head of Institution & Project Coordinator PAN Number of Head of Institution One Colored Photograph of Head of Institution & Project Coordinator List of Computers with Configuration Details Biodata of Project Coordinator Biodata of Academic Faculties along with the copy of their self attested Educational certificates

Yes

No

Date:..

Authorized Signatory (with Name)