National Institute of Mass Communication

84-A , Bharat Nagar, Opp. D-904, New Friends Colony, New Delhi-110065
Ph:26320885, 26320887, 26827450, 26827451, e-mail: nimc2003@yahoo.co.in

2010 - 2011

No.
Attested
Photograph
Application for admission to...........................................................................................

1. Name of the Applicant (In Block Letters)

2. Father's Name

3. Mother's Name

4. Nationality 5. Date of Birth 6. Sex

Date Month Year

7. Demand Draft No. 8. Dated 9. Amount (In Rs.)

Date Month Year

10. Complete Address for Correspondence (Do not repeat name) :

State Pin Code Telephone No.

11. Complete Permanent Address (Do not repeate name):

State Pin Code Telephone No.

E-mail

12. Details of Educational qualification (From X standard onwards) :

Name of the Year of Marks

University/Board Percentage
Qualifying Exam Passing obtained
13. Write in about 200 words your reason for joining the course, please use separate sheet.

14. Do you have prior media experience.

Y N (if yes, please give details)

15. Documents to be enclosed

a) Birth Certificate
b) Qualification
c) Prior work done in media (if any)
d) Demand Draft

DECLARATION

1. I hereby certify that all the particulars furnished by me are true to the best of my knowledge
and if found guilty of furnishing wrong information, my admission is liable to be cancelled.

2. All student exercises/ production done in the institution will be the property of the institution
including the copyrights and I will have no claim on them.

3. I will handle the institution's equipment with extreme care and all damage and losses
caused by me will be paid by me.

4. I also admit that fees once paid will not be refunded.

..........................................
Signature of the Candidate

FOR OFFICE USE ONLY

Admitted / Rejected :

Remarks, if any :