Application Form

Form No.:

Space for
attested
Photograph

FAKIR MOHAN UNIVERSITY

VYASA VIHAR, NUAPADHI, BALASORE - 756 020

Application form for admission into _________________________________ (Course Applying for)

(FOR OFFICE USE ONLY)

Index No. ............................

Category : General / SC/ST/PH/OBC/Ex-Serviceman ...........................

Class Roll No ......................

Date of Admission ....................................................................................

ADMIT

ENDORSED

HEAD OF THE DEPARTMENT/COURSE CO-ORDINATOR

1. Name of the Applicant

CHAIRMAN P.G. COUNCIL

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

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

(in capital letters)

a) Permanent Address

...........................................................................................................
...........................................................................................................
b) Corresondence Address :

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

c) Telephone Number with code :

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

d) Mobile Number

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

..................................................................... (as in H.S.C. Certificate)

2. Date of Birth

Date

Month

Year

(in words ............................................................................................)

3. Sex : Male / Female

4. Marital Status :

Married / Unmarried

5. Nationality ........................... 6. Mother Tongue ......................................................................................

7. Fathers Name

:.................................................................................................................

8. Mothers Name

:.................................................................................................................

9. Guardians Name

:.................................................................................................................

(if other than Father / Mother)

10. Occupation of Father / Guardian :.......................................... Mother ..................................................

11. University Registration No:.....................................................................................................................
(for students who have passed from this University)

12. Academic Qualification :

Degree/
Diploma

Board /
University
Passed /
Appeared

Total Marks
Secured

Maximum
Marks

Division /
Class /
Honours /
Distinction

Year of
Passing

Main / Optional
Subject
offered

HSC

+2 Arts /
Sc. / Com.
+3 Arts /
Sc. / Com.
P.G.
Any other
Degree
* Attested Copies of Marks sheets / Certificates of all examinations to be enclosed.

13 Mention whether SC/ST/OBC/Ex-Serviceman

(Attach Certificate)
14. Mention if Physically Handicapped with
50% disability (Attach Certificate)

Yes / No

15. Bank Draft No. ...........................................................

Date ...........................................

Issuing Bank ..............................................................

Amount .....................................

DECLARATION
I do hereby declare that the particulars furnished in this form are true to the best of my knowledge and I
shall abide by all rules and regulations framed by the University from time to time. I shall forfeit my candidature
in case of fraud or misrepresentation of facts on my part.

Date ...............................

Full Signature of the Applicant

UNDERTAKING
BY A STUDENT FOR ADMISSION INTO POST-GRADUATE DEPARTMENTS OF

FAKIR MOHAN UNIVERSITY

Vyasa Vihar, Nuapadhi, Balasore - 756020
I do hereby undertake that in the event of my admission, I shall abide by the rules of
the University and the Hostels attached to it. I also hereby undertake that in case of any
indiscipline / disobedience or violation on my part of the rules laid down by the University
or any authority empowered by them in this regard or should my conduct in the University
be found not satisfactory my name will automatically be removed from the University
register. I also undertake to abide by the decision regarding examination fixed by the
authorities of the University.

Countersigned

Signature of Father / Mother / Legal Guardian

Full Signature of the Applicant

Date .......................................

FAKIR MOHAN UNIVERSITY

VYASA VIHAR, BALASORE, ODISHA

ADMIT CARD FOR ENTRANCE TEST

Space for
attested
Photograph

2011 - 2012
Name of the Department / Programme ...................................................... Index No. .................................
Name of the Candidate ...........................................................................................................................
Full Signature of the Candidate ...............................................................................................................
You are allowed to appear at the P.G./M.Phill/M.Tech Entrance test at F.M. University campus as per the
following schedule. Any malpractice or misconduct at the entrance examination will disqualify you from
selection. You are required to produce this admit card at the time of written test.

Date of Entrance Test :

Time of Entrance Test :

Head / Course Co-ordinator

Department / Programme of ________________

Form No.I

P.G. CENTRAL OFFICE

FAKIR MOHAN UNIVERSITY
VYASA VIHAR, NUA PADHI, BALASORE, ODISHA

UNDERTAKING

I, Mr/ Ms. .......................................................................................................... Son / Daughter of Sri /

Smt. ......................................................................................... AT : .....................................................
PO : ......................................... Ps : ................................................... Dist :.......................................
a student in the Department of ..............................................................................................................
Fakir Mohan University, Balasore do hereby undertake that I shall not resort to any kind of ragging
activities or any other acts of misbehavior in the Department / Hostel premises / Campus of the
University or outside. In case, it is found that I am involved in such activities, I shall accept any
punishment; even to the extent of rustication; as to be decided by the University authorities from time
to time.

I agree.

Signature of Parent / Guardian

with date

Signature of the Applicant

with date

Form No.II

P.G. CENTRAL OFFICE

FAKIR MOHAN UNIVERSITY
VYASA VIHAR, NUA PADHI, BALASORE, ODISHA

FORM OF UNDERTAKING GIVEN BY A STUDENT

WHOSE AGE IS 18 OR
OVER AT HIS/HER ADMISSION TO THE UNIVERSITY

I agree to abide by the rules of the University and / or Hostel attached to it and to
withdraw myself from the College should the authorities of the F.M. University decide that such
withdrawal is necessary in the interest of the institution.
I further agree that while taking part in any study tour / research tour / excursion / picnic or any
tour sponsored or conducted by the University or the Department, I will do the same at my own
responsibility and in case of any accident during the same resulting in any injury to my person/property
of death, neither the University nor the Department, nor any of its employees wil be responsible for the
same either under civil or criminal law. No other Institution / Department / Corporation / Company /
Film / State/ Union or Individual will be responsible for such accident if their vehicle / accommodation
/ amenities are used for any of the above purpose, at the request / requisition of the University or of
the respective department and involved in the accident.

Date ..............................

Signature of the Student (in full)

Department .....................................

Signature of Nature of Legal Guardian (in full)

Address

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