INDIRA GANDHI NATIONAL OPEN UNIVERSITY

MAIDAN GARHI, NEW DELHI-110 068

APPLICATION FORM FOR ADMISSION IN DIPLOMA IN ELEMENTARY EDUCATION PROGRAMME - JULY-2011
(To be submitted only at concerned Regional Centre)
FORM NO.

INSTRUCTIONS
1.
2.
3.
4.
5.
0

Please read the instructions in the information brochure before filling up the form.
Use BLACK BALL POINT PEN in boxes using English capital letters or English numerals.
Do not make any stray marks on this sheet.
Do not staple, pin, wrinkle scribble, tear or wet this sheet.
Write in CAPITAL LETTERS only within the box without touching the lines as shown in the Sample below.
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1. Regional
Centre Code

9 A

B C

F G H I

M N O P

2. Programme
Centre Code

6. Sex

7. Marital Status

(Write the relevant

code in the box)

(Write the relevant

code in the box)

(Write the relevant code

in the box)
A1 - Married
B2 - Unmarried

A1 - Male
B2 - Female

10. Date of Birth

Date
Month

R S T

3. State
Code

5. Nationality

A1 - Indian
B2 - Others

U V W

X Y

A1 - GEN C3 - ST
B2 - SC D4 - OBC
(Write the relevant (In case of OBC student, Please
also
indicate code either)
code in the box)
D4A or D4B
i ) Cremy Layer - D4A
ii) Non-Creamy Layer - D4B

9. Religion (Write the relevant code in the box)

(Write the relevant

code in the box)
A1 - Yes
B2 - No

A1 - Hindu
D4 - Sikh
G7 - Paris
B2 - Muslim
E5 - Jain
H8 - Jews
C3 - Christian F6 - Buddhist I9 - Others

11. Social Status (Write the relevant

12. Whether Kashmiri Migrant ?

code in the box)

A1 - Ex-service man
B2 - War window
C3 - Not applicable

13.

Territory

disability (write the relevant code)

C3 - Employed
A1 - Unemployed
B2 - IGNOU Regular Employee
D4 - KVS Employee

A1 - URBAN
B2 - RURAL
C3 - TRIBAL

A1 - Yes
B2 - No

(Write the relevant

code in the box)

15.a. Whether a person with

14. Employment Status

4. Category

8. Whether Minority:

Year

CONTROL NUMBER :

A1 - Yes
B2 - No

16.a. Are your registered

with (Ignou)

16.b. If yes write the Enrol. No. & Program Code in the boxes below :

(Write the relevant code in the box)

Enrolment No.

15.b. If a person with disability (nature of

disability) (Write the relevant code in box)
A1 - Hearing Impaiment
B2 - Locomotor Impaiment
C3 - Visual Impaiment
D4 - Reading Disability
E5 - Any other, Please specify

17. Medium Code

A1 - English
B2 - Hindi

Programme Code

(Write the relevant

code in the box)

If other please specity :

A1 - Yes
B2 - No

18. Details of Scholarship being received if any :*b) Dept. Offering (Write the
(a) Annual Scholarship
Amount

(c) Family income (yearly)

relevant code in the box)

Scholarship
A1 - Govt Deptt.
B2 - Other

Fold from here

19. Name of the Candidate (Leave one box empty between First Name, Middle Name & Surname

(d) Please indicate in (e) In case of Jail Inmates

case of below poverty (Write the relevant code in
the box)
line
A1 - Yes
A1 - Yes
B2 - No
B2 - No

20. Name of Father/Mother/Husband (Strike out whichever not applicable)

21. Educational Qualifications : (Graduation and onwards)

(c) Year of Passing
(a) Qualification
(b) Main Subjects

(last 2 digit only)

Code

(d) Division

(01, 02, 03 or 04)

for pass

22. Optional Subject (Code)

(i) Group B - Content-based methodology Courses (Two)

23. Write name & Complete Mailing Address

(in BLACK BALL Point Pen only)

(e) % of marks

(Do not use

decimal)

(f) Board Code

(Whether required)

(II) Group C - Special Course (One)

24. For Office Use

Exam Centre Code :

26. Photograph

Name :
Exam Centre Code :
Address :

25. Candidates Signature

PIN CODE :

53

Affix your latest

passport size
photograph
(4cm x 5 cm) duly
attested by
Gazetted Officer

27. Address for Correspondence (Do not give Post Box No. Leave a box between each unit of address like House No.,
Street Name, P.O., etc.) Do not repeat Students Name/Fathers Name

City

District

State

Pin Code

28. Telephone Number (if any) with STD Code/Mobile No.

STD Code
Telephone No.

29.

Mobile No. (if any) with STD Code

STD Code
Telephone No.

30. E-mail address/ID (if any)

31. Teaching Experience (Please give details chronologically including present employement)
Name of the school Nature of post (temporary/
Permanent) with years
with address

Total Full Time Teaching

Experience

Type of School (Govt./Govt Registration Post held (PGT/TGT/Primary

aided/unaided)
No.of the
Teacher/Asst. Teacher)
School

Years

No. of
years

Months

Employment Certificate
(To be provided by the Principal/Headmaster/Headmistress)
This is to certify that Mr./Ms............................................................................................... has been teaching in this school since
................................................................... as Post Graduate/Graduate/Primary/Assistant Teacher teaching at Sr. Sec. / Secondary/
Prmary level and He/She is a full time temporary/permanent teacher of this school. He/She has ...................................................
years of teaching experience. This school is Govt./Govt. aided/unaided and is duly recognised by the central or a state
government or a union territory.
Signature of Principal/Headmaster/Headmistress
Name : ................................................................
Designation : ......................................................
Name of School : ................................................
Registration number of School: .........................
Place : ...........................
Address of School : ............................................
Date : .............................

Seal/Stamp .........................................................

INSTRUCTIONS FOR CANDIDATES

1.
2.
3.
4.
5.
6.

Please send your Application form by Regd. Post/Speed Post to the Regional Centre under whose jurisdiction area you
are Teaching. Details of Regional Centre are given in Annexure-I in the student handbook and prospectus.
Application form submitted to any other Regional Centre will not be entertained.
The last date for the receipt of filled in application form at the concerned Regional Centre is 30th June, 2011. Application
received after this date will not be accepted.
Please retain the photocopy of the form for future reference.
No documents are to be attached with this application form.
Application form received without employment certificate will be rejected.

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Emplo yme nt Ce r tific ate

(To be provided by the Principal/Headmaster/Headmistress)
This is to certify that Mr./Ms. .................................................................... ............ has been teaching in this School
since .................... as Post Gra du ate/Gra du ate/Primary/Assista nt Tea cher teaching at Sr. Sec./ Secondary/Prima ry
level and he/she is a full time temporary/permanent teacher of this school. He/She has ............. .............................
years of teaching experience. This school is Govt./Govt. aided/unaided and is duly recognised by the central or a state
government or a unioin territory.

Signature of Principal/Headmaster/Headmistress
Na me : ............................................................
Designation : ...................................................
Name of the school : ........................................
Registra tion No. of the school :.........................
Address of the school : .....................................
........................................................................
........................................................................

Place : .........................................
Da te : ..........................................

(Seal /Stamp)

Cate g o r y Ce rtific ate (I)

(i) SC/ST Candidate s
T his is to certify tha t Mr./Ms./Mrs. ............................................................... ....................son/da ughter/wife of
Shri ............................................................................ of Village ....... ........................................................... Town
.................................................... Distt. .............................................. State/U.T. .......................................... belongs
to ................................................... Caste which is recognised a s Scheduled Ca ste/ Schedu led T ribe u nder the
Constitu tion.
(Scheduled Caste Part C States) Order 1951 read with the SC/ST list (Modification Order, 1956).
Mr./Ms./Mrs. ....................................................................................... ............. and his/her family reside in Village/
Town ................................. District ......................................... Sta te/U.T. ...................................

(Signature of Tehsilda r/Commissioner/District Magistrate)

Pla ce : ......................

Signature ..................................

Date : .......................

Sea l/Sta mp ................................

Cate g o r y Ce r tific ate (II)
(ii) O BC Candidate s (o nly no n-c r e amy laye r )

This is to certify tha t Mr./Ms./Mrs. ............................................................... .....................son/da ughter/wife of

Shri ............................................................................ of Village ....... ........................................................... Town
.................................................... Distt. .............................................. State/U.T. .......................................... belongs
to ................................................... Caste who are eligible for availing the benefits as per Central list of 5 to 13 Cs/
OBC as per Resolution No. 12011/68/93-DCC(C) of Ministry of Social Justice & Empowerments as modified from
time to time by that Ministry based on the advice of the National Commission for Backward Classes. (NCBC).
Mr./Ms./Mrs. ....................................................................................... ............. and his/her family reside in Village/
Town ................................. District ......................................... Sta te/U.T. ...................................

(Signature of Tehsilda r/Commissioner/District Magistrate)

Pla ce : ......................

Signature ..................................

Date : .......................

Sea l/Sta mp ................................

C e r t if i c at e
This certificate duly filled-in and signed is to be submitted to the Regional Centre concerned after receiving the letter
of offer for a dmission to B.Ed. after entrance test.)
I hereby u ndertake tha t the school will provide facilities to Mr./Ms. .............................. ..................... needed for
carrying practical work for the B.Ed. programme. This school is Secondary/Higher/Senior Secondary School.

Signature of Principal/Headmaster/Headmistress
Na me : ...................................................................
Designation : ........................................................
Name of the school : ............................................
Address of the school : .......................................
...............................................................................
...............................................................................

Place : .........................................
Da te : ..........................................

(Seal /Stamp)

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