ANNAMALAI UNIVERSITY

DIRECTORATE OF DISTANCE EDUCATION Application for Admission to Certificate / Diploma / P.G. Diploma / Under Graduate / Post Graduate / SPOT CODE Double Degree Programme including Lateral Entry 2013 - 2014 (REFER PROSPECTUS FOR DETAILS) (Make a tick-mark ( ) in square q wherever applicable)
1. Programme Code & Name

APPLICATION NO.

FOR OFFICE USE ONLY ENROLMENT NO.

Double Degree Programme 2. PCP Zone (See Prospectus)

PASSPORT SIZE PHOTO q Lateral Entry/Direct II/III Year Programme q duly signed and attested by an authorised Medium: English q Tamil q officer

3. OPTIONAL SUBJECT CHOSEN : (See Prospectus) U.G. Programmes : Part-I : Optional Papers : I Year: II Year: III Year: P.G. : I Year: Programmes (optionals) 4. Name in CAPITAL LETTERS (In English): II Year:

5. Fathers Name / Husbands Name

6. ADDRESS IN CAPITAL LETTERS (to which communications and lessons are to be sent)

PIN Dist. State E-mail ID 7. Date of birth (in the Christian era) (as entered in the School Leaving Certificate) 8. Sex: Male Date Phone No. (with STD Code) Mobile No. : Month 1 Year 9

9. Nationality: Female q q Others (specify) Muslim q Christian q q ST MBC BC OC DNC

10. Religion: Hindu

11. Community to which the applicant belongs: SC 12. Are you differently abled? YES Percentage 13. Qualifying Examination Passed: Duration of Name of the Programme Examination Main : Ancillary :

q NO q Blind q Others
Name of the University/Board Reg. No. and Year % of Marks Class Obtained

Application Fee ` 100/- in person and ` 130/- by post.

14. Pattern of passing the Degree Examination: 15. Occupation : 16. Are you presently undergoing any other programmes, in any institution (including DDE)? If yes, give details :

11+1+3 q 10+2+3 q 11+2+2 q (10+2+2 pattern and Direct OUS PG Degree not Eligible) Government
No q q

Non-Government q Others q q

Yes

DECLARATION
i) I declare that the particulars given above are correct and I submit myself to the disciplinary and regularly jurisdiction of the authorities of the University who are vested with the rights to exercise discipline under the Act, the Statutes, and the Ordinances, and will strictly observe

the rules and regulations that have been framed thereunder by the University. ii) I hereby agree that with regard to disputes arising in all matters including admission, returning of original certificates after verification, sending of lessons, PCPs, response sheets, examinations, remittance of fees, etc., only the Courts and Tribunals having jurisdiction over Annamalainagar (Chidambaram), Cuddalore District, Tamilnadu and not over any other place, shall have jurisdiction for the purpose of filing a suit or preferring complaint under the Consumer Protection Act or any other law for the time being in force or for taking any legal action against the Directorate of Distance Education or the Controller of Examinations, Annamalai University.

Place: Date: Signature of the Applicant

Enclosures: (1) Photostat Copy of Degree Certificate/Pass / Provisional Certificate q (4) Identity Card duly filled in q (Check List) (2) Photostat Copy of Mark List or Consolidated Mark List (5) Photostat Copy of Community Certificate q q (3) Photostat Copy of Transfer or Migration Certificate (6) Scanning Slip q

(Do not enclose original certificates)

FOR OFFICE USE ONLY

CERTIFICATES VERIFIED 1) Degree/Provisional/Pass Certificate 2) Transfer OR Migration Certificate 3) Mark List (10th/12th Standard) 4) 8th Standard Transfer Certificate 5) 10th Standard Transfer Certificate Name of the Bank q Draft/Challan Number q Amount q Date q q

ELIGIBLE

NOT ELIGIBLE q q

REMITTANCE PARTICULARS : : : :

Provisionally selected for admission. Spot selection subject to confirmation by the Director

Official-in-Charge

Section Head For use in Spot Admission

Officer-in-charge

Whether Original Certificate/Mark Lists No q received after verification? Yes q

Whether Lessons received Yes q No q Incomplete set q If yes, Complete set q

Signature of the Candidate Admission Confirmed

Official-in-Charge

Section Head

DIRECTOR