Application No……………………. Reg.No ………………………
PANDIT JAWAHARLAL NEHRU COLLEGE OF AGRICULTURE AND RESEARCH INSTITUTE, KARAIKAL – 609 603, U.T. of Puducherry (Sponsored by Govt. of Puducherry and Affiliated to Tamil Nadu Agricultural University, Coimbatore)
Application for admission to B.Sc.(Agri.) for the academic year 2012-2013
Tick the appropriate columns wherever necessary
1. Name of the Candidate : ………………………………………………… (in BLOCK LETTERS with initials at the end) Attested Photo of the Candidate
2. Name of the Father / Guardian : ………………………………………………….
3. Name of the Mother : ………………………………..…………………
4. a) Permanent Address :
………………………………………………………………..…… …………………………………………………………….….…… ………………………………………………………….….……… .…………………………………………………………………….
PIN CODE
b) Address for Communication :
…………………………………………………………………… …………………………………………………………………… …………………………………………………………………… .…………...……………………………………………………….
PIN CODE
Phone No. (with STD code) : …………………………………………………… Mobile No. : …………………………………………….……... Email ID. (Optional) : …………………………………………………….
The application downloaded from website should be accompanied with a Demand Draft of Rs.500/- (General) / Rs.250/- (SC/ST) Last date for the receipt of filled in application : 13.06.2012 [Wednesday] Read Information Bulletin of PAJANCOA&RI 2012-2013 before filling the application
5. Sex : Male / Female
6. a) Date of Birth : (Enclose an attested copy Date, Month and Year should be entered Date Month Year of the birth certificate or SSLC / only as a two digit number. Example: Matriculation mark statement) 2nd July 2011 to be entered as 02.07.11
b) Age (as on 01.07.2012) :
c) Place of Birth : ……………………………………………………………
7. Nationality : Indian / Others
8. Quota under which the candidate claims seat : Puducherry Other States / Foreign / NRI UT UTs
9. Region to which the candidate claims seat [as special allocation] [Applicable only for candidates from U.T. of Puducherry] Tick whereever necessary
Karaikal Mahe Yanam
10. Community [Puducherry UT candidates are to fill Column (a) and Other States/UTs Candidates to fill Column (b)]
a) Puducherry UT b) Other States / UTs
Community SC BT EBC MBC BCM OBC Others SC ST Others
11. Other Special Allocations, if any [Applicable only for candidates from Puducherry UT]
Freedom Differently abled Wards of Sports Wards of Village Fighter Ex-service men Personnel Farmer Extension Workers
12. Details of SSLC / Matriculation Examination Examination Month & Year Marks Maximum Name of the School and Address Passed of Passing Secured Marks
13. a) Details of Qualifying Examination Passed Reg.No. Examination Month & Year Name of the School Name of University / Passed of Passing and Address Board
b) Qualifying Examination H.Sc. (Academic – H.Sc. (Academic – Central H.Sc. H.Sc. State Board) Board) (Vocational Agriculture for U.T. Equivalent of Puducherry only)
c) Appearance in which the Qualifying Examination Passed FIRST SECOND
d) Whether Admission Sought with Improvement Marks [Marks secured in the first improvement examination only will be YES / NO considered. The candidate has to enclose attested copies of regular and improvement mark sheets] e) Particulars of Institutions last studied Academic Year Name of the Institution Class Studied Place State 2011-2012 2010-2011 2009-2010
14. Total marks in the qualifying Examination : Marks Secured ______Max.marks______[in all subjects put together]
15. Subject-wise marks in the Qualifying Examination
a) H.Sc. (Academic / Equivalent) b) Vocational Group (For U.T. of Puducherry students only) Name of the Vocational subject :…………...... …… Subjects Code Marks Maximum Subjects Code No. Marks Maximum No. obtained marks obtained marks Mathematics 1 Biol./Chem./Econ 8 /Home Sci. Physics 2 Mathematics 9 Chemistry 3 Physics 10 Biology 4 Vocational-I 11 Botany 5 Vocational-II 12 Zoology 6 Vocational – III 13 * Computer Science 7 / BioTech/ Mic.Bio/Bio.Chem/ Hom.Sci. Including marks secured in the Practical, if any
16. Medium of Instruction (in Qualifying Examination) Tamil English Others
17. Religion : Buddhism Christianity Hinduism Islam Jainism Sikhim Others
18. Mother tongue : Hindi Kannada Malayalam Tamil Telugu Urdu Others
19. When admitted, will you be the first person in your family studying in a Professional college?
Yes No
20. Occupation of parent / guardian : Agriculture Industry Business State Govt. Central Govt. Private Small Trade Others organization
21.(a) Annual income of parent / guardian: [evidence to be enclosed]
Rs.30000 Rs.30001 – Rs.1,00,001 – Rs.2,00,001 – Rs.3,00,001 – Rs.5,00,001 – Above and below Rs.1,00,000 Rs.2,00,000 Rs.3,00,000 Rs.5,00,000 Rs.10,00,000 Rs.10,00,000
b) Actual income per annum : Rs…......
22. Civic status of the place in which the Institution you have studied last, is located: Corporation Municipality Township Town Village Others Panchayat Panchayat
DECLARATION BY THE APPLICANT
I, ……………………..……………… Son / Daughter of ……………...... ………………….….. hereby solemnly declare that the information furnished and the statements given in the application and the enclosures are true, correct, complete and no relevant fact is suppressed. I further declare that should it be found otherwise, I will be liable to forfeit my seat and / or removal from the rolls of the Institution at whatever stage of study I may be, besides making me liable for criminal prosecution. I shall abide by the rules and regulations of the Centralised Admission Committee and PAJANCOA&RI, Karaikal.
Place: Date : Signature of the Applicant
DECLARATION BY THE PARENT / GUARDIAN
I, …………………………………………. Parent / Guardian of …………...... ……………………. hereby solemnly declare that I am fully aware of the declaration given by the Applicant, my Son / Daughter / Ward and I declare and bind myself on the same terms contained in the above declaration. The statements and the information given in the application and the enclosures are true, correct, complete and no relevant fact is suppressed. If it is found otherwise, the applicant is liable to forfeit the seat and / or removal from the rolls of the Institution at whatever stage of study he/she may be, besides making him / her liable for criminal prosecution. I shall abide by the rules and regulations of the Centralised Admission Committee and PAJANCOA&RI, Karaikal.
Place : Signature of the Parent / Guardian Date :
CHECK LIST (Please √ mark in the relevant boxes against the items which are enclosed along with the application)
1. Duly filled application 2. Attested copy of age proof 3. Attested copy of the statement of marks of SSLC / Matriculation Examination 4. Attested copy of the statement of marks of H.Sc.(Academic / Vocational-Agriculture) 5. Attested copy of the Permanent Integrated Certificate 6. Nationality Certificate in Form A 7. Community Certificate in Form B (if applicable) 8. U.T. of Puducherry residents in Form C and Residence Certificate in Form D 9. Nativity Certificate (if applicable) in Form E 10. Attested copy of the certificates for special allocation [Sl.No.9 & 11 ] 11. Certificate of Registration for French Nationals of Indian Origin 12. Acknowledgement Card (Self addressed and stamped) 13. Evidence for Foreign National / NRI Quota. 14. Details of Demand Draft enclosed.
Amount Drawn in Bank D.D.No. & Date
Total No. of Enclosures :
Signature of the Applicant
Note: All the original certificates should be surrendered at the time of admission. FORMAT OF CERTIFICATES
(CANDIDATES MAY EITHER USE THESE FORMATS DIRECTLY OR TAKE PHOTOCOPIES FOR SUBMITTING NECESSARY CERTIFICATES ALONG WITH ADMISSION APPLICATION)
FORM - A NATIONALITY CERTIFICATE
Certified that Shri./Smt./Kumari ...... son/wife/daughter / ward of Shri./ Smt……………………………………………………………………… ...... residing at ...... is an Indian national.
Place : Deputy Tahsildar / Tahsildar Date : Name of the Officer: (Office Seal)
FORM - B CASTE CERTIFICATE
Certificate to be produced by the applicant belonging to OBC / MBC / BCM / EBC / BT in support of his / her claim for the purpose of admission to educational institution and academic purpose
I. This is to certify that Shri./Smt./ Kumari ...... son/ wife /daughter /ward of Shri./Smt ...... in the Union Territory of Puducherry belongs to ...... community which is recognised as a Back ward Class in the Union Territory of Puducherry vide Serial No ...... as per the
(i) GO. Ms. No.9-2001 - Wei. (SW-II) dated 19-02-2001 and published in the official Gazette of Puducherry Vide Gazette No. 29 dated 22.02.2001. (ii) G.O.Ms. No. 13/2002 - Wei. (SW-II) dated 12.03.2002 and published in the official Gazette of Puducherry Vide Gazette No. 13 dated 26.03.2002. (iii) G.O. Ms. No. 26/2002 - Wei. {SW-II) dated 10.06.2002 and published in the official Gazette of Puducherry Vide Gazette No. 117 dated 26.06.2002. (iv) G.O. Ms. No. 56/2003 - Wei. (SW-II) dated 01.12.2003 and published in the official Gazette of Puducherry Vide Gazette No ...... dated ……………………….
of the welfare Secretariat, Government of Puducherry, drawn up the list of other Backward Class based on the recommendation of the state level commission for backward classes.
Shri./ Smt./ Kumari ...... and his/her family ordinarily reside(s) in the above mentioned place.
Note ; For residents of Puducherry, the caste certificate should be obtained only from Puducherry Authorities.
Place : State / Union Territory Signature Date : Name of the Officer
Designation (Office Seal)
Certificate to be produced by the applicant belonging to SCHEDULED CASTE or SCHEDULED TRIBE in Support of his / her claim
1. This is to certify that Shri./Smt./Kumari ...... son / daughter of Shri./Smt./ ...... of Village/Town ...... the Stale/Union Territory ...... belongs to the ...... Scheduled Caste/ Scheduled Tribe under : The Constitution (Scheduled Castes) Order, 1950* The Constitution (Scheduled Tribes) Order, 1950* The Constitution (Scheduled Castes) (Union Territories| Order, 195 I* The Constitution (Scheduled Tribes) (Union Territories) Order, 1951 * As amended by the Scheduled Caste and Scheduled Tribes lists (modifications) order, 1956, the Bombay Re-organisation Act, 1960, the Punjab Re-organisation Act, 1966. the State of Himachal Pradesh Act, 1970 and the North Eastern Areas (Re-organisation) Act. 1971 and the Scheduled Castes and Scheduled Tribes Order (Amendment) Act, 1976. The Constitution (Jammu and Kashmir) Scheduled Castes Order, 1956* The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959* The Constitution (Dadra and Nagar Haveii) Scheduled Castes Order, 1962* The Constitution (Dadra and Nagar Haveii) Scheduled Tribes Order, 1962* The Constitution (Puducherry) Scheduled Castes Order, 1964* The Constitution (Ultar Pradesh) Scheduled Tribes Order, 1967* The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968* The Constitution (Goa, Daman and Diu) Scheduled Tribes Order, 1968* The Constitution (Nagaland) Scheduled Tribes Order, 1970*
2. This certificate is issued on the basis of the Scheduled Caste / Scheduled Tribe Certificate issued to Shri. / Smt ...... father / mother of Shri. / Smt. / Kumari ...... of Village / Town …...... in District / Division ...... of the State / Union Territory ...... who belongs to the ...... Caste / Tribe which is recognised as a Scheduled Caste / Scheduled Tribe in the State/ Union Territory...... issued by the…………………………….. (Name of the prescribed authority) vide their No ...... dated ......
Place : State/Union Territory Signature Date : Designation (with seal of Office) * Please quote specific Presidential Order. FORM - C
INFORMATION TO BE FURNISHED BY APPLICANT APPLYING FOR PUDUCHERRY RESIDENTS QUOTA SEATS
Declaration by the applicant: 1. I am an Indian national / French national of Indian origin and not having any other nationality # 2.1 am a Puducherry resident based on the certificate furnished below.
Signature of the applicant # Strike out whichever is not applicable. FORM - D RESIDENCE CERTIFICATE
1 . Candidates seeking admission under Puducherry residents quota seats must furnish Permanent Integrated Certificate as per G.O.Ms.No.13, Dt.24.02.2007.
OR
2. Certified that Shri./ Smt...... father / mother of Shri. /Smt. /Kumari ...... is an employee of Central/State Government/Defence Personal/ Central Paramilitary Forces/ ...... (a public sector under taking wholly or substantially run by the central Government / UT Administration) and that he/she is presently posted and serving in Puducherry UT) since ...... (Please indicate the date from which he/she has been serving in Puducherry UT.) Name : Designation :
Place : Head of the Office Date : (Office Seal)
OR
3. Certified that Shri ./Smt ...... father/ mother of Shri. /Smt. / Kumari ...... was a Defence Personnel /Central Paramilitary Force and was killed/disabled in action during the year ...... Name : Designation : Place : Head of the Office / O.C. of Unit Date : (Office Seal)
OR
4. Certified that Shri./ Smt ...... father / mother of Shri. /Smt./ Kumari ...... was a Puducherry Government employee/Central Government employee/Employee of...... which is a Public Sector Undertaking run wholly/substantially by the Central Government / Puducherry Administration and lie / she died while in service in Puducherry Union Territory on ...... Name : Designation :
Place : Head of the Office Date : (Office Seal) FORM - E
5. (a) Certified that Shri./ Smt...... Designation …...... father/mother of Shri./ Smt./ Kumari …...... …...... is a Central Government servant/Defence Personnel / an employee of ...... (a public sector undertaking wholly or substantially run by the Central Government / Puducherry Administration) and that he / she is presently posted in Puducherry, Union Territory of Puducherry as his / her home town (Enclose separately document to prove that you have declared any place in Puducherry as your home town.)
Place: Head of the Office with seal
Date: Office seal
NATIVITY CERTIFICATE
(b) This is certify that Shri. /Smt./ Kumari ...... son/daughter of Shri./Smt ...... residing at ...... who has applied for ...... is a native of the Union Territory of Puducherry by virtue of continuous residence for …...... years /birth vide Reg.No...... of …...... Municipality / Commune Panchayat.
Place : Deputy Tahsildar / Tahsildar Date : Name of the Officer:
FORM - F CERTIFICATE TO CLAIM SEATS UNDER KARAIKAL / MAHE / YANAM REGIONAL ALLOCATION a) Certified that Shri./Smt./ Kumari...... has passed the S.S.L.C./Matric. Brevet/Higher Secondary /any other higher public examination in the year ...... and has for that purpose undergone academic studies continuously for three successive classes in the following recognized institution(s) in the region of Karaikal / Mahe / Yanam of U.T. of Puducherry. S.No. Name of the Institution(s) Date(s) attended 1. 2.
Place : Signature of the Head of the Institution Date : last attended with office seal b) Certified that the Shri./Smt./Kumari ...... son /daughter of Shri./Smt ...... is having continuous residence for the last five years at ...... which comes under Karaikal/Mahe/Yanam Region of Pondicherry UT.
Place: Deputy Tahsildar / Tahsildar Date: Name of the Officer (Office Seal)
FORMAT OF CERTIFICATES FOR U.T. OF PUDUCHERRY/OTHER STATE/UT QUOTA SEATS 1) Certificate of Nationality, SC/ST, shall be in the format as prescribed by the respective State/ UT Government. Note: Form A, B, C, D, E and F issued by the competent authorities as mentioned in the Information Bulletin of the CENTAC 2012-13, Govt. of Puducherry may be followed. INSTRUCTIONS TO CANDIDATES
INSTRUCTIONS TO THE CANDIDATES
Completed application form should reach the Dean, PAJANCOA&RI, Karaikal on or before 13.06.2012 [Wednesday] at 5.00 pm in the published notification and application form.
Applications SHOULD NOT be interchanged among the candidates.
All columns should be correctly and completely filled-in. Enclosures should be completed in all respects.
Application form with incomplete particulars will be SUMMARILY REJECTED.
Application forms received after the prescribed date and time will not be considered on any account. The College authorities will not take any responsibility for postal delays. The candidates are advised to post their applications well in advance without waiting till the last date for sending the application.
Candidates should read the Information Brochure carefully and completely before filling in the application form.
The candidates should ensure that correct marks and community category are furnished in the application. The candidates are informed that after scrutiny, if any information is found to be incorrect, then
i) They will forfeit the admission no matter at what stage of the course the student will be at that time;
ii) Legal proceedings will be initiated against him / her for furnishing false information.
iii) Candidates should write their mailing address in the acknowledgement card and affix postage stamp of sufficient value.