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Pandit Jawaharlal Nehru College B.Sc

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Pandit Jawaharlal Nehru College B.Sc 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 ...............................................................
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