DECLARATION - DOC by 5YTB7e

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									               North Eastern Regional Institute of Management NERIM
               Management Wing : Padma Nath Sarmah Bhawan, Jaya Nagar, Khanapara, Guwahati-781022
                : 91-0361-2234999, Fax : 91-0361-2234900, Email : nerimindia@yahoo.com; Website : nerimmba.org     Estd. - 1992
               IT Wing : Parukutty Bhawan, Nabin Nagar, Guwahati-781024
                : 91-0361-2453293, Fax : 91-0361-2452450, Email : nerimindia@yahoo.com; Website : nerimmca.org
                                                                                                                      One recent
                                                                                                                   Passport (Colour)
                                    APPLICATION FORM FOR ADMISSION                                                 size Photograph


FORM NO. :

          NAME OF THE COURSE APPLIED FOR

          SESSION

1.      Name of the applicant ( in Block Letters)

2.      Father’s / Mother’s / Husband’s Name

3.      Address                         Home address                                               Contact address




                     Phone :                                                       Phone :


4.      Date of Birth (By English Calendar)

                                                                        Day               Month                     Year

5.      Age as on 01-01-200….

6.      Educational Records
      Examination Passed                  Year       Class/Division     Total marks    % of Marks     Medium University / Board
      BA/BSc/BCom/BBA/BCA/
      BSc (Agril)/ BE/ LLB (5-yr)
      HS (Arts/ Science/Commerce)

      HSLC / CBSE/ SSLC

      Others (if any)


7.      Name of the College last attended


8.      Subjects passed in Degree Examination


9.      Proficiency in Language (s)


10.     Nationality and Home State

11.     Community to which belong (Tick- )                     GEN           SC          ST         OBC          MOBC       Others
                                            DECLARATION
I……………………………………………………………………………………...do hereby declare that
the particulars furnished by me in the application are correct and true in all respects. I stand to forfeit my
admission if any information provided in this Application Form is found to be false and incorrect. I further
declare that I shall obey all the rules and regulations and orders of NERIM during my period of
undergoing the programme and I shall be liable for any damage caused by me to any property of the
Institute including Computer Hardware, Library Books, Furniture and Fixtures etc.
I also declare that I shall abide by the Rules and Regulations prescribed by the University so as to make
me eligible for the award of ………………………………… Degree by the University.
Further it is declared that while a student of the …………………………..course I shall not prosecute any
other course of study or hold any Part time / Full time employment elsewhere.



Date:                                                                         Signature of the applicant

I do hereby authenticate the above statement made by my son / daughter / wife to be true.
I undertake to extend the full financial support to his / her required for the whole course of study.
I also undertake that I will be liable for the liability created by his / her, if any.



Date:                                                                 Signature of the Parent / Guardian

The following Documents are to be submitted
1.      A Conduct certificate obtained from the Head of the Institute / College last attended must be
        enclosed with the application.
2.      Attested Photocopies of Marksheet / Certificates should be submitted with the application.
3.      Passport size Photograph should be pasted on the space specified in the form.
4.      SC/ST/OBC Certificate (if any applicable) should be enclosed.
5.      Gap certificate (if applicable) should be enclosed.
6.      All original testimonials must be produced at the time of Personal Assessment Test.
7.      Completed Application Form with relevant documents must reach the office of the Institute on or
        before the notified date.

     Selected for Admission to 1st Semester ………………………………Course, 200……….
         (Vide Sl. No………………of the selection List dated…………………………)
                                             May be Admitted

        Date…………………..                                         Head, Deptt. of …………………………..
                                                    ADMIT

            Registrar                                                                      Director
        Date :……………..                                                                Date :………………

        Fees Received Rs ……………………….Vide receipt No………………………….

        Date :…………………                                                                      Cash Collector

								
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