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)
1. NAME OF THE APPLICANT
(as given in the certificate in
CAPITAL LETTERS)
8. Physically Challenged (Tick
)
9. Present Occupation
5. Religion (b) Age
(c) Sex (Tick
) 4. Nationality
7. Mother Tongue
Yes
No
OC
/ BC
/ MBC
/ SC
/ ST
Male
/ Female
NAME :
S/o, D/o, W/o, C/o. :
Door No. & Street :
Town / Village Post :
District :
State : INDIA
Pin code :
Phone (Res) : Off.
Registered Mobile No. : E-Mail
(a) in English :
(b) in the Regional
Language :
2. Name of Father / Mother /
Guardian / Husband
3. (a) Date of Birth as per Christian era
b) Caste
PG PG PG PG PG
APPLICATION NUMBER
Name of the Course
applied for I / II
Medium (Tick
)
TAMIL
ENGLISH
STUDY CENTRE / SPOT ADMISSION CENTRE AT WHICH ADMISSION IS MADE
Centre
Code
PERSONAL CONTACT PROGRAMME CENTRE
Centre
Code
Place
Main Subject
Place
Candidate to tick () any one of the appropriate boxes
for Tuition Fee Consession - (Refer to Page No. 18) Differently Abled Prison
ACADEMIC YEAR 2013-2014
CALENDAR YEAR 2014
A 1
C 1
3
4
10. Are you undergoing any other course in a College or
University? If so, specify
11. The wards of Defence Personnel / Ex-Servicemen (a) Ward of Defence Service Personnel
should specify as : (b) Ward of Ex-Servicemen : Navy / Army / Air force.
12. DETAILS OF EXAMINATION PASSED
Examinations passed
Name of the Board / University
Month & Year of Registration Class with Maximum
with Subjects
with the Name of the
Passing Number Grade/Marks Marks
School / College
Enclosures
(1) ....................................... (3) ................................................. (5) ..............................................
(2) ....................................... (4) ................................................. (6) ..............................................
I hereby declare that all the particulars given above are correct and I agree to abide by all the Rules and Regulations
of the University that are in force from time to time.
Station :
Date : SIGNATURE OF THE APPLICANT
FOR OFFICE USE ONLY
1. Whether the application is in order : Yes / No
2. If not, Documents required :
(1) ............................................. (3) .............................................
(2) ............................................. (4) .............................................
ADMISSION / CANCELLATION ORDER
3. Thiru/Tmt./Selvi ........................................................................................ is admitted provisionally / not admitted
to the................ Degree Course in .............................................................................Main in English/Tamil Medium
during the Academic Year 2013-2014 / Calendar Year 2014.
CO-ORDINATOR
Spot Admission Centre / Study Centre DIRECTOR
4. Admission / Cancellation Intimation sent on ........................................................
5. Certificates returned to the Candidate on ........................................................
(1) Statement of Marks (2) S.S.L.C Book (3) Conduct Certificate
(4) Birth Certificate (5) Transfer Certificate (6) ..............................
ASST. /ASST. SECTION OFFICER SECTION OFFICER ASSISTANT REGISTRAR
STUDY CENTRE / SPOT ADMISSION CENTRE / OFFICE
Signature of the Centre Co-ordinator with Seal DIRECTOR
S.S.L.C.
Strikeout whichever is not applicable
(State whether it is 10 Years or 11 Years Course)
P.U.C. / Higher Secondary
Strikeout whichever is not applicable
(State Whether it is One Year
or Two Years Course)
Diploma Course
Strikeout whichever is not applicable
(State Whether it is Two Years
or Three Years Course)
(The above statement must be attested by the same Gazetted Officer/Assistant Registrar/
Public Relation Officer (IDE) / Faculty who attested the Photograph)
UNIVERSITY OF MADRAS
INSTITUTE OF DISTANCE EDUCATION
COMPUTER CODING SHEET
POSTGRADUATE COURSES 2013-2014 / 2014
M.A.
M.Music
M.Com.
M.Sc.
2. Main Subject chosen
3. ENROLMENT NUMBER (to be assigned by the office)
Academic Year 2013-2014
Calendar Year 2014
4. Name of the Candidate (Write in Capital Letters) (a) in English (b) in the Regional Language
5. Name of Father / Guardian / Husband (Write in Capital Letters)
as per entry in the Transfer Certificate
6. Mothers Name (Write in Capital Letters)
7. Date of Birth
9. Address for communication (do not write your name here)
City Pincode
Phone Mobile E-Mail
Date Month Year
1. Course to which admission is sought
8. Sex Male
Female
A 1
C 1
3
4
(a)
(b)
10. Medium of instruction opted English
Tamil
11. Nationality Indian Others 12. Region Urban Rural
13. Religion
14. Caste
15. Community SC
ST
MBC
BC
OC
16. Physically challenged YES NO
17. Are you employed? YES NO
18. Centre at which you propose to attend
the Personal Contact Programme classes
19. Centre at which you propose to collect the
study materials (Refer Page No. 44-52)
20. Are you a ward of a Defence Service
Personnel ? (Army / Navy / Air Force)
21. Are you a ward of an Ex-service person? Yes No
22. Tuition Fee Concession Opted ?
(Candidate to tick (
)
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