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For Office Use only

Transaction ID: 8228466/MBBS

ALIGARH MUSLIM UNIVERSITY


Session: 2011-12 Affix (don't staple)
Application Form for Admission to Self Attested
Photograph of
M.B.B.S./B.D.S. size 2.5 x 3cm

FACULTY OF MEDICINE

Bank: STATE BANK OF INDIA, DD/CR No.: 526356, Date: 2011-03-23, Amount: 350 Nationality: INDIAN

Order of Preference of Branches:


__________________________________________________________________________________________________
1. MBBS 2. BDSB 3. -- 4. -- 5. -- 6. -- 7. -- 8. -- 9. --
Preference for Test Centres:
__________________________________________________________________________________________________
1. LUCKNOW 2. ALIGARH
Personal Details:
__________________________________________________________________________________________________
Name: MOHD AQUIB FAROOQUI Father's Name: MOHD ATHAR FAROOQUI
Date of Birth: 01-05-1993 Mother's Name: QAISAR JAHAN
Gender: MALE Parent's/Guardian's Monthly Income: 90000
Religion: ISLAM Rural/Urban: URBAN

Details of Qualifying Examination: Status & Special Categories:


__________________________________________________________________________________________________
Examination: AISSCE Status: EXTERNAL
Roll No.: 5668851 Enrolment No.:
Year of Passing/Appearing: 2011 Hall:
Board/Univ.: CBS Special Categories: 1. -- 2. -- 3. --
Marks Obt./Max. Marks: /
Remarks (if any): RA

Course(s) Studied/Studying other than Qualifying Examination (Starting from the latest):
__________________________________________________________________________________________________
Course Yr. of Passing/Appearing Board/Univ. Roll No.
AISSE 2009 CBS 5228896

Permanent Address: Address for Correspondence:


__________________________________________________________________________________________________
Address: 504,A/1 AZAD NAGAR NEAR RELIAN Address: 504,A/1 AZAD NAGAR NEAR RELIAN
CE TOWER BANDA CE TOWER BANDA
BANDA - 210001(UP) BANDA - 210001(UP)

Phone 1: 9628596989 Phone 2: 9628596989 Email ID: joinatakibfarooqui@gmail.com


If admitted, is hostel accomodation required? YES
__________________________________________________________________________________________________
DECLARATION: I SOLEMNLY UNDERTAKE to accept and abide by the rules of the Aligarh Muslim University and all the decisions of the Academic
Council & other appropriate University bodies in regard to my admission. I hereby solemnly affirm that I have gone through the Guide to Admissions
2011-12 and solemnly declare on oath that the entries made by me in the above columns are true to the best of my knowledge and belief and if at any
time, the entries are found incorrect, the admission may outrightly be cancelled and disciplinary action may be initiated against me.

Transaction ID: 8228466/MBBS

__________________________
Thumb Impression Signature of the Candidate
Male: Left Thumb, Female: Right Thumb
List of enclosures attached with the Application Form: FOR OFFICE USE ONLY

1. DD/Cash Receipt in Original

2. Self Attested copy of HS/SS Certificate in support of date of Birth


3. Copies of Marksheets/Grade Sheets of all previous Examinations
passed/appeared including parts therein after passing High School
Signature of Scrutiny Officer
4. If employed, copy of No Objection Certificate from the employer

5. Copy of documents in support of Special Categories clamied, if any Identity & Original Documents Verified
The candidate is eligible/not eligible for admission to
6. Copy of document(s), if rusticated/debarred or convicted by a court of law ____________________________________
7. ________________________________________ Remarks ____________________________
8. ________________________________________
Verifying Officer ____________________
Hall Allotted:
Dept. of ___________________________
Date ____________________
Clearance by Proctor DSW

Address Slips (for Office Use):


---------------------------------------------------------------------------------------------------------------------------------------
Name: MOHD AQUIB FAROOQUI Name: MOHD AQUIB FAROOQUI
Address: 504,A/1 AZAD NAGAR NEAR RELIAN Address: 504,A/1 AZAD NAGAR NEAR RELIAN
CE TOWER BANDA CE TOWER BANDA
BANDA - 210001(UP) BANDA - 210001(UP)
Tel./Mobile: 9628596989 Tel./Mobile: 9628596989
---------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------
Name: MOHD AQUIB FAROOQUI Name: MOHD AQUIB FAROOQUI
Address: 504,A/1 AZAD NAGAR NEAR RELIAN Address: 504,A/1 AZAD NAGAR NEAR RELIAN
CE TOWER BANDA CE TOWER BANDA
BANDA - 210001(UP) BANDA - 210001(UP)
Tel./Mobile: 9628596989 Tel./Mobile: 9628596989
---------------------------------------------------------------------------------------------------------------------------------------
(For Office Use only)
Aligarh Muslim University
Scan Card, 2011-12
Transaction ID: 8228466/MBBS
M.B.B.S./B.D.S.

Affix (don't staple)


NON-ATTESTED
Name: MOHD AQUIB FAROOQUI Photograph of
Address: size 2.5 x 3cm

504,A/1 AZAD NAGAR NEAR RELIAN


CE TOWER BANDA
BANDA - 210001(UP)
Tel./Mobile: 9628596989

Thumb Impression
Male(Left Thumb)/Female(Right Thumb)
Specimen Signature of the candidate

ACKNOWLEDGEMENT SLIP, AMU, Aligarh


Application form for admission to: To,
M.B.B.S./B.D.S., 2011-12 Name: MOHD AQUIB FAROOQUI Rs. 6/-
has been received. Address: 504,A/1 AZAD NAGAR NEAR RELIAN Postage Stamps

R. No. is: _______________________ CE TOWER BANDA


BANDA - 210001(UP)
Transaction ID: 8228466/MBBS
Tel./Mobile: 9628596989
POSTAL SLIP
Application Form for Admission to
M.B.B.S./B.D.S.

To,
DEPUTY CONTROLLER (ADMISSIONS)
ADMISSION SECTION, AMU,
ALIGARH - 202002 (UP)

From:
Name: MOHD AQUIB FAROOQUI
Address: 504,A/1 AZAD NAGAR NEAR RELIAN
CE TOWER BANDA
BANDA - 210001(UP)
Tel./Mobile: 9628596989

---------------------------------------------------------------------------------------------------
Aligarh Muslim University
CANDIDATE'S SLIP
(Keep this Slip with you for future reference)
Course Applied for: M.B.B.S./B.D.S.
Transaction ID: 8228466/MBBS Test Date: 29.5.2011
Password: 1993-05-01
_______________________________________________________________________________
INSTRUCTIONS

1. Please ensure that you have appended Photographs, Thumb Impression and Signature at the designated places on
the Application form.
Note: a) Use identical good quality color photographs taken not earlier than 3 months. The photographs should be taken preferably
wearing dark clothes on a white background.
b) Your Thumb Impression & Signature establish your identity hence, do not merely write your name in capital letters.

2. You must Ensure that all the documents along with Demand Draft/Cash Receipt is attached with the Application
Form.
Note: Demand Draft (valid for 6 months) of the requisite amount should be drawn in favor of FINANCE OFFICER, AMU, payable at
Aligarh.

3. You must NOT make any type of correction(s) / modification(s) on the Application Form else your candidature may be
rejected.

4. Paste the ‘POSTAL SLIP’ given above on the A-4 size Envelope containing the Application Form and send it on the
Pre-Printed Address.

5. Please be a regular visitor to our website: www.amucontrollerexams.com which will provide you with necessary
updates regarding the status of your Application Form/Admission Test results etc.