To be submitted at the time of

Registration for Examination

Application form
Central University of Orissa
Koraput
Application Form for Entrance Examination – 2013-14
1. NAME OF THE CANDIDATE AS IT APPEARS IN THE SCHOOL LEAVING CERTIFICATE (IN CAPITAL LETTERS)

APPLICATION
FORM
INCOMPLETE
IN ANY
2. Date of Birth 3. Gender RESPECT
SHALL NOT BE
Day Month Year CONSIDERED
Gender Female

4. Nationality 5. CATEGORY 6. Are You Blind? 7. Do you belong

to Physically
General Yes No
Indian Handicapped
S.C. 8. STATE OF DOMICILE
Foreigner,
country,
S.T. Yes
if foreign National
…………………… O.B.C. (Non Creamy No
Layer)

9. Programme for study Foreign National

M.A.
10. Choice of Subject 11. Entrance
/M.Sc. Exam Center
Code
Subject Name / Code
Central
University of
Orissa, Koraput

12. Details of Bank Draft / Challan enclosed towards Entrance Examination Fee
DATE OF DEMAND DRAFT/ CHALLAN
D.D. / I.D NUMBER D D M M Y Y AMOUNT

13. Father’s Name (IN BLOCK LETTERS)

Mother’s Name (IN BLOCK LETTERS)

14. YOUR COMPLETE POSTAL ADDRESS INCLUDING YOUR FULL NAME 15. PHOTOGRAPH
(WRITE IN CAPITAL LETTERS, USE BALL POINT PEN WITH BLACK INK). Application No.
Paste here firmly your
recent colour
Name……………………………………………… photograph of good
Address…………………………………………… quality
……..………………………………………….…… (Size 3.5 CM x 4.5
CM)
…………..………………………………………… Do not staple
………………………………………………………
………………………………………………………
Pincode:
16. Signature (within Box) in running
hand using black ball point pen only Do not get the
photograph attested
(Do not sign in capitals)

17. Academic Records: Note : Taken into account only marks in the subjects which are counted for awarding
class/division.
Examination passed Year of % of Name of Name of Subject/Papers
passing and Marks School/College/Institution Board/University Offered
Division OGPA or and District in which
Grade situated
High School / Matriculation /
10th Class
Senior School Certificate
(10+2) Intermediate or
equivalent
B.A./B.A.(Hons.)/B.Com
/B.Com (Hons.)/B.Sc./
B.Sc.(Hons.)/B.Tech/B.E.
/M.B.B.S.
Any other Graduate
Degree……………………

Aggregate
M.A./M.Sc./M.C.A

Any other P.G. Degree

Aggregate
Any other examination please
specify…………………………
………………………………
………
*Strike off the Name of Examination which is not applicable.
18. Details of present employment
Organization & Address Position held Period Nature of Duties

19. Name of the Parent/Guardian/Legal guardian and Address:_________________________________

__________________________________
__________________________________

20. Annual family income 21. Parent’s/Guardian’s Occupation

Less than Rs. 50, 000/- per year Agriculture Public Govt. Service
Business Private Service
Between Rs. 50, 000/- to Rs. 1,00,000/- per year
Medical Defense Service
Between Rs. 1,00,000/- to Rs. 2,00,000/- per year
Engineering Teaching/Research
Above Rs. 2,00,000/- per year
Law Practice Others

2
21. Whether need a seat in the hostel? Yes /No

DECLARATION BY THE APPLICANT

I declare that the information furnished by me in the Application Form is true in all respects and incase any
entry or information is found to be false, this shall entail automatic cancellation of my admission besides rendering
me liable to such action as the University may deem proper. I hereby undertake that I have carefully gone through
the eligibility conditions prescribed in the website www.cuo.ac.in for the programme I am applying for and shall
appear in the entrance examination after satisfying myself that I do fulfill the same. If at any stage it is found that I
do not fulfill the minimum prescribed eligibility criteria, my admission, if granted, shall stand cancelled and I shall
have no right to admission whatsoever. Further I undertake that I will be abided by all rules and regulations
prescribed by the University authorities.

Signature of the Applicant

Date……………… Telephone No. with STD Code ……………………………….. Fax No………………………

Place ……………………………… Mobile No. ………………………………..…..

E-Mail…………………………………

Note: Student can appear in any two programmes offered by Central University of Orissa, Koraput.
Separate applications/ fees has to be submitted at the time of registration for entrance examination if the
student wishes to appear in two programmes.