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UG App Form 2024 25

The document is an application form for admission to an undergraduate course in mathematics and computing. It requests personal details, educational history, payment details, and required documents. Admissions are based on preferences of test centers, category, and other eligibility criteria.

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xx69dd69xx
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© © All Rights Reserved
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151 views6 pages

UG App Form 2024 25

The document is an application form for admission to an undergraduate course in mathematics and computing. It requests personal details, educational history, payment details, and required documents. Admissions are based on preferences of test centers, category, and other eligibility criteria.

Uploaded by

xx69dd69xx
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 6

INSTITUTE OF MATHEMATICS AND APPLICATIONS

(Science &Technology Department, Govt. of Odisha)


Andharua, Bhubaneswar-751029

APPLICATION FORM FOR ADMISSION INTO UG COURSE

Paste your recent


Reference Number passport size
photograph (Color)
2 0 2 4 UG and append your full
signature.
For Office use only

(Full Signature)
INSTRUCTION: Fill in the application form in your own handwriting clearly and legibly.
Incomplete and duplicate forms may be rejected.

NAME OF THE COURSE: B.Sc. (HONS.) IN MATHEMATICS AND COMPUTING

Choice of Preferences of Test Centre: Please mention the centre code in order of
preference. (Refer Information Brochure for the list of examination centre codes.)

Preference 1:
Preference 2:
Preference 3:

APPLICATION FEE PAYMENT INFORMATION *

Amount Paid

Transaction ID

Date of Transaction

* Application fee once paid is not refundable.

Page 1 of 6
GENERAL INFORMATION

(Please leave one blank between two words)

1. Name of the
Candidate:
(In capital letters)

2. Father’s Name:

3. Mother’s Name:

4. Category: GENERAL ST SC
(Tick whichever is
applicable)

5. Whether Persons With Disability (PWD) (Write YES/NO in the Box):

D D M M Y Y Y Y
6. Date of Birth (As recorded in the High School Certificate):

7. Email ID:
(Please write your valid email ID)

8. Mobile No:
(Please write your valid mobile number)
9. Aadhaar
Number:
(Please write your valid Aadhaar number)

10. Address for Correspondence (In capital letters):

Page 2 of 6
11. Permanent Address (In capital letters):

12. Mother Tongue:

13. Gender:

14. Religion:

15. Marital status:

16. Nationality:

EDUCATIONAL RECORD

17. Education details:

Name of the Board/ Name of the Year of Stream Division/ % of % of Marks


Examination University College/Institution passing Grade Marks/ in
CGPA Mathematics
Matriculation/
High School
Certificate
Examination or
equivalent
Higher
Secondary/
Equivalent
Examination

Page 3 of 6
Others, if any

18. Name of the Institution where last studied :

19. Name of the Board/ University where last studied:

OTHER INFORMATION

20. Occupation/Designation of Mother_______________________________ Father_______________________________

21. Total annual income of the household (gross):_________________________________________________________

22. Details of contact person in case of emergency

Name: ___________________________________________________________________________________________________

Address ___________________________________________________________________________________________________

______________________________________________________________________________________________________________

Mobile No._________________________________________________________________________________________________

Relationship with the candidate: _______________________________________________________________________

Page 4 of 6
DECLARATION

I certify that the information furnished in this application is true to the best of my
knowledge. My application may be rejected and admission be cancelled, if any information herein is
found to be incorrect at any time even after admission.

PLACE: SIGNATURE OF APPLICANT


DATE: (Full Signature)

(CHECK LIST OF DOCUMENTS)


*****
[Please put a tick mark in the appropriate box]

1. Photo copy (self-attested) of High School certificate:


2. Photo copy (self-attested) of High School Mark sheet:
3. Photo copy (self-attested) of Intermediate/Higher Secondary certificate:
4. Photo copy (self-attested) of Intermediate/Higher Secondary Mark sheet:
5. Photo copy (self-attested) of the valid caste certificate (If belong to ST/SC candidates of Odisha
state domicile.):
6. Photo copy (self-attested) of the valid certificate (If belong to Persons With Disability (PWD) ):
7. Photo copy of details of application fee:
8. Two self-addressed envelopes:
9. Two recent passport size photograph:

Total Number of document pages submitted: (in figure) _________________________________________________

(in words) ___________________________________________________________ paged from ____________ to ____________.

PLACE: SIGNATURE OF APPLICANT


DATE: (Full Signature)

Page 5 of 6
(FOR OFFICE USE ONLY)

Mr. / Ms.__________________________________________________________________________ has been selected

/ wait- listed for taking admission into____________________________________________________________

_________________________________________________________________________________________________________

ACADEMIC SECTION I/C ADMISSION IN-CHARGE

ADMISSION AND COURSE FEE PAYMENT DETAILS

Amount Paid

Transaction ID/Demand Draft Number

Date of Transaction /Date of Demand Draft

Issuing Bank Name

Money Receipt No. and Date

ACCOUNTS SECTION I/C DIRECTOR

Page 6 of 6

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