BANARAS HINDU UNIVERSITY
(Established by Parliament by Notification N.225 of 1916)
FACULTY OF SCIENCE
APPLICATION FORM FOR ADMISSION TO PG DIPLOMA / CERTIFICATE COURSE
INSTITUTE OF SCIENCE SESSION-2016-2017
(TO BE FILLED IN BY THE APPLICANT ONLY)
1. Name of the Applicant:--------------------------------------------------------------------------------Affix
Passport
size photo
2. Fathers Name
:---------------------------------------------------------------------------------
3. Mothers Name
:---------------------------------------------------------------------------------
4. Date of Birth
:------------------------------------------------------------------------------------------------------
5. Address for
:------------------------------------------------------------------------------------------------------
Correspondence
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
6.
Permanent Address :-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
7. (a) Telephone/Mob.
:----------------------------------7. (b) E-mail I.D. :--------------------------------------------
8. Category of Applicant:
9.
SC
(a) Institution last attended
Name & Address of the Institution
ST
OBC
Emp.W.
General
Last Examination Passed
Stay
from
9.
to
(b) Present Association with BHU
Name
&
Address
studying/employee
of
the
Department
Where Name of course if from
students
to
10. Academic Record:
Result
Examination Passed
University/Board
Year of
Passing
Division With % of
aggregate marks
Subject
Offered
[Link] school or Equivalent
2. 10+2 or Equivalent
3. [Link].(Hons.)or Equivalent
4. [Link]. or Equivalent
11. Details of Qualifying Examination:
Name of Examination &
Passing year
Subject Offered
RESULT
Percentage of Marks
In the relevant subject
In aggregate
1-----------------------------2-----------------------------3-----------------------------4-----------------------------Hons. In--------------------
12. Status of Applicant
Nationality
State
Religion
Married/Unmarried
Mother Tongue
DECLARATION BY THE APPLICANT
(a) I solemnly declare that this form has been filled in by me and that the above statements/entries are
true ; and that my admission is liable to be cancelled in case of my discrepancy in the information
given above being detected at a later stage.
(b) I agree to abide by the rules of the faculty and of the University and promise to be regular in my
studies and to pay my tution and other fee regularly.
(c) I under take that I shall not accept any employment nor shall seek admission elsewhere during my
studies in the Banaras Hindu University.
Date-----------------------------
-----------------------------------------(Full Signature of the Applicant)
DECLARATION OF THE PARENTS OR GUARDIAN
In the event of my above mentioned son/daughter/ward being admitted in P.G.
Diploma/Certificate Course, Faculty of Science, B.H.U. I hold myself responsible to his/her conduct in
and even outside University Campus and for the payment of his/her fee and other dues of the
University.
Date-------------------------
------------------------------------------------------(Full Signature of the Applicant)
Name------------------------------------------------------------------------------
Address-------------------------------------------
(Signature of the attesting Officer)
------------------------------------------------------
With Office Seal
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NO OBJECTION CERTIFICATE FROM PRESENT INSTITUTION
This department has no Objection to Mr./Mis.-----------------------------------------------------------------Attending the Course-------------------------------------------------------------in the Faculty/Institute of
__________ Banaras Hindu University in the session 2016-17.
Date----------------------------
--------------------------------------------------------Director
of
Institution/Dean
of
Faculty /Coordinator of School/Spl.
Courses/Head of the Department