Application Number:

ARBHATTA KNOWLED UNIVERSITY, PATNA

Aryabhatta Centre for Nanoscience & Nanotechnology
APPLICATION FORM –2015

1. PROGRAMME APPLIED FOR : M.Tech. Ph.D.

(Strike out which is not applicable) PHOTOGRAPH
2. Programme Code : Affix your latest
passport size
3. Research Discipline : (4 cm  5 cm)
photograph duly
attested by you
4. Enrolment Number :
(To be issued by the University)

5. (a) Are you already Registered with A.K.U. : (A1 - YES, B2 - NO)
(b) If YES, write the Enrolment No. and Programme Code

6. Date of Birth
Date Month Year
9. Name of the Applicant (Leave one box blank between First, Middle and Surname)

10. Father’s/Husband’s/Mother’s Name (Strikeout whichever is not applicable)

11. Address for Correspondence (Please do not give Post Box No. Leave a blank box between each unit of address)

City District

PIN Code State

12. Landline Telephone Number (if any) with STD CODE 13. FAX Number (if any)
STD CODE Telephone Number STD CODE FAX Number

14. Mobile No. 15. Email Address/ID (if any)

16. Nationality : A1 - Indian, B1 - Others

17. Gender 18. Category 19. Territory Code
(Write the relevant Code in the box) (Write the relevant Code in the box) (Write the relevant Code in the box)
A1 – Male, A1 – GEN, B2 – SC, C3 – ST, A1 – Urban,
B2 – Female, D4A – OBC (Creamy), B2 – Rural,
C3 – Others D4B – OBC (Non Creamy) C3 – Tribal
20. Marital Status (Write the relevant Code in the box) 21. Religion (Write the relevant Code in the box)
A1 – Married, A1 – Hindu, B2 – Muslim, C3 – Christian
B2 – Unmarried D4 – Sikh, E5 – Jain, F6 – Budhist
G7 – Parsi, H8 - Jews, I9 – Others
22. Minority 23. Social Status 24. Kashmiri Migrant
(Write the relevant Code in the box) (Write the relevant Code in the box) (Write the relevant Code in the box)
A1 – Yes A1 – Ex-servicemen A1 – Yes
B2 – No B2 – War Widow B2 – No
C3 – Not Applicable
25a. Differently Abled 25b. If yes, give Nature of Disability
(Write the relevant Code in the box) (Write the relevant Code in the box)
A1 – Yes A1 – Speech and Hearing Impairment D4 – Low Vision
B2 – No B2 – Loco motor Impairment E5 – Any other,
C3 – Visual Impairment pl. specify ________________
26. Employment Status 27a. Below Poverty Line 27b. Annual Family Income
(Write the relevant Code in the box)
A1 – Unemployed A1 – Yes
B2 – A.K.U. Employee B2 – No Rs.
C3 – Employed
D4 – KVS Employee
28a. Are you in Receipt of any of these Scholarships? 28b. If Yes, please specify Agency and Amount (Rs. _________per year)
(Write the relevant Code in the box) (Tick which is applicable)
A1 – Yes OTHERS (Pl specify)
B2 – No. UGC CSIR ICMR DST ICSSR ICHR

29. Details of Educational Qualifications (from Graduation onwards)

Sl. Name of the University Year of Subjects Percentage

No. Examination Passing of Marks

30.Details of Science education and Research activities . (If any)

31. Details of Application Fee (A Demand Draft or `1000/- in favour of Registrar, Aryabhatta Knowledge University, payable at Patna
should be paid as application fee.

Amount : Rs. . DD Number :

DD Date : Place of Bank :
Date Month Year
Name of the Bank :

DECLARATION BY THE APPLICANT

I hereby declare that I have read and understood the conditions of eligibility for the academic programme for which I seek the
admission. I fulfil the minimum eligibility criteria and I have provided the necessary information. I also declare that the information
submitted above is true and correct to the best of my knowledge. In the event of any information being found incorrect or
misleading, my candidature shall be liable to cancellation by the University at any point of time even after award of Degree and I
shall not be entitled to refund of any fee paid by me to the University. Further, I have carefully studied the rules of the University as
printed in the Prospectus and I accept them and shall not raise any dispute in the future over the same rules.

Dated :
__________________________Signature of the Applicant