Indian National

JAMIA HAMDARD (HAMDARD UNIVERSITY)

HAMDARD NAGAR, NEW DELHI - 110062

Form.No.

Application Form For Ph.D. / P.G. / U.G. / Diploma & Certificate Courses Admission-2012

INCOMPLETE APPLICATION IN ANY RESPECT SHALL NOT BE CONSIDERED

(1) Read the Information Bulletin & Prospectus-2012-13 carefully before filling in form. NOTE: Please attach a Demand Draft for Application Fees of Rs. 500/- plus Rs. 250/- for each preference of

IMPORTANT INSTRUCTIONS

course. For example - If you choose two preferences than you have to pay Rs. 500 + 250 + 250 = 1000/-. (2) Please fill in all the entries in CAPITAL LETTERS using a BLACK BALL POINT PEN only. (3) Fill bubbles with black ball point pen only. (4) DO NOT STAPLE/PIN ANY DOCUMENT WITH THIS FORM (Use Clip). (5) Same form can be used for applying for admission to more than one programme. However, the candidate has to enclose test processing fee according to the number of programmes he/she is applying for. Separate form should be filled for separate discipline.

Application for :

Ph.D/M.Phil Courses

Post Graduation Courses

Under Graduate/Diploma/Certificate/Pre-Tib Courses

1. Preference(s) for Admission (Write programme codes in the boxes in order of preference for admission. See information Bulletin & Prospectus - 2012 - 13 for programme codes)
1st preference Programme Code 2nd preference Programme Code 3rd preference Programme Code 4th preference Programme Code 5th preference Programme Code 6th preference Programme Code 7th preference Programme Code 8th preference Programme Code

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0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

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0 1 2 3 4 5 6 7 8 9

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Paste 3.5 3.5 cm Size Color Photograph within this box

(Not to be signed)

Signature of Applicant

2. Name as in class 10th certificate (Use CAPITAL LETTERS only. Leave a blank box between First, Middle & Last Names). Fill the circle accordingly.
3. Jamia Hamdard Employees Ward
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Yes No
4.Social Category 6. Religion
Budhism Christianity Hinduism Islam

GEN SC ST

1 2 3

1 2 3 4 5 6 7 8

5. Category
Physically challenged Sports person Yes No

Jainism Parsi Sikhism Others

7. Date of birth Day Month Year

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

(See information Bulletin & Prospectus 2012-13 for Codes for filling in the boxes shown below)

12. Qualifying Exam. Details (See Information Bulletin & Prospectus 2012-13 for Codes)
Qualifying Exam Code Board/University Year of Passing / Appearing Percentage MAT/CMAT/CAT/GPAT (Score) NET Qualified (for Ph.D) Yes If NET Qualified

8. Centre Choice
(All the choices have to be filled) Centre 1 Centre 2 Centre 3

9. Internal Candidate Information 1 2

11.State of Domicile

1 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
MoU Cat for Ph.D Yes No

NET (JRF)

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

3 4 5

NET (LS) from UGC/CSIR

10.Gender
Male Female

Other equivalent exam from Govt. Agencies

1
No

1 2

GD/Interview will be conducted in Jamia Hamdard, New Delhi.

Form.No. ________________

13. Nationality: Indian Yes

No

If No, Specify Nationality:

15. Fathers Name: 16. Mothers Name: 18. Name: S/o or D/o: Address: PERMANENT ADDRESS

14. Parents Monthly Income: Rs. 17. Name: S/o or D/o: Address: MAILING ADDRESS

City/District: State: Phone No. (Local Delhi, if any): 19. Details of Examination Passed Examination High School (Class 10th) 12 / Intermediate 1 Yr Graduation
(write the name of the degree)
st th

Pin : Mobile No.

City/District: State: STD Code: Email : Mobile No. Phone No.:

Pin :

Name of School / College & Place

Board / University

Subject (In Abbreviations)

Year of Passing

% or Grade

2nd Yr 3rd Yr 4 Yr 5 Yr
th th

Post-Graduation
(write the name of the degree)

1 Yr 2 Yr 3 Yr
rd nd

st

Almiyat Fazeelat Any Other

20. Have you ever been debarred from any exam/rusticated from any School/College/University/Institution. If yes,
Reason Name of the School / College/ University / Institution

Yes

No
Year

21. Have you ever been enrolled in Jamia Hamdard?

Yes

No
Year Enrollment Number

If yes,
Name of the regular course enrolled

22. DETAIL OF PAYMENT Draft No. Date of Issue Amount Drawee Bank

23.

DECLARATION BY THE APPLICANT

I ........................................................................................................S/O or D/O ..................................................................................................... declare that all the statements given in this application form are true to the best of my knowledge. I understand that if any of the statements is found wrong my admission will stand cancelled. If admitted, I will abide by the rule & regulations in force in Jamia Hamdard and as amended from time to time and pay the prescribed fee regularly.

Date : D D

M M

Y Y

Fathers Signature

Mothers Signature

Signature of Applicant

Name of the Candidate