0

Roll No.
vuqdzekWad

DR. RAM MANOHAR LOHIA AVADH UNIVERSITY, FAIZABAD-224001 (U.P.) Affix Coloured
Passport Size
MkW0 jke euksgj yksfg;k vo/k fo’ofo|ky;] QStkckn&224001 ¼m0iz0½ Camera Facing
Photograph
COUNSELING AND ADMISSION FORM FOR RESIDENTIAL COURSES - 2010 ikliksVZ vkdkj dk
vkoklh; ifjlj ikB;Øe gsrq dkmfUlfyax ,oa izos'k izi= & 2010 dSejs dh rjQ eq[k
djds [khapk x;k
uohure jaxhu
Details of the Demand Draft for Admission Fee
QksVksxzkQ fpidk;sAa
Name of the Issuing Bank: Tick9Your Caste Category
Place: Date:
Amount: Demand Draft No: … … … …
Course Code: Course Applied: UR OBC SC ST

1. Name of the Course to which admission is sought……………………………………………………………...........

fo"k; dk uke ftlesa izos’k pkfg;s
2. Name (In Block Letters in English)………………….....................…...........……(in Hindi)…………………………
uke ¼vaxszth ds cM+s v{kjksa esa½ ¼fgUnh esa½
3. Date of Birth………………………………...…………………………………………………………………...........................
tUe frfFk
4. Father’s/Husband’s Name…………………………………………………………………………………...........................
firk@ifr dk uke
5. Mother’s Name…………………………………………………………………………………………....................................
ekrk dk uke
6. Address for Correspondence ……………………….………………………………………………………………….........
i=kpkj dk irk ………………………….………………………………………………………........................
………………………….………………………………………………………........................
……………………….………………....Pin Code.…………...……………….......................
¼fiu dksM½
Phone No.(nwjHkk"k)………………......………….......E-mail …………………............................
7. Permanent Address ………………………….………………………………………………………........................
LFkkbZ irk ………………………….………………………………………………………........................
…………………….…………………………………………………………………................
……………………….………………....Pin Code.…………………………...........................
¼fiu dksM½
8. Category (Please Tick 9for vertical reservation)
Js.kh ¼lgh 9dk fu’kku yxk;s m/okZokj vkj{k.k gsrq½ … … … …
UR OBC SC ST
9. Nationality……………………...................…………...…………… Religion………………………………………………............
jk"Vªh;rk /keZ
10. Category for horizontal reservation: Physically Handicapped … Freedom Fighter … Ex Soldier …Kargil Shaheed …
Js.kh {kSfrt vkj{k.k gsrq% 'kkjhfjd :i ls fodykax Lora=rk lsukuh HkwriwoZ lSfud dkjfxy 'kghn

Kashmir Migrant … University/College Permanent Teacher/Employee Ward (For RCAT Candidates Only) …
dk'ehj foLFkkfir fo’ofo|ky;@egkfo|ky; LFkk;h f’k{kd@deZpkjh vkfJr ¼dsoy vkoklh; ifjlj izos'k ijh{kk ds vH;fFkZ;ksa gsrq½

11. Particulars of the last examination passed on the basis of which admission is sought.
ftl ijh{kk ds vk/kkj ij izos’k pkfg;s ml ijh{kk dk fooj.k
(a) Name of Examination………………………….........……… (b) Year of Passing/Appearing ………….......……………........….
ijh{kk dk uke mRrh.kZ gksus dk o"kZ@lfEefyr
(c) Roll Number……………........……………………………… (d) University/Board ……………………......…………….......……
vuqdzekad fo'ofo|ky;@cksMZ
(e) University/Institution Last Attended…….......……………… (f) Subject(s) in Final Year of Qualifying Exam .……..........…..….
fo'ofo|ky;@laLFkk tgkWa i<+rs Fks vgZdkjh ijh{kk ds vafre o"kZ ds fo"k; ................…....................….
..................................

Signature of the Counselor

(For Office use only)
12. Details of Earlier Examinations Passed
fiNyh mRrh.kZ ijh{kkvksa dk fooj.k

S.N. Class University/ Year Subject(s) Max. Marks Marks Division/ Remarks
dz-la- d{kk Board o"kZ fo"k; vf/kdre vad Obtained Percentage fooj.k
fo'ofo|ky; izkIrkad Js.kh@izfr’kr
@cksMZ
1. High School
¼gkbZ Ldwy½

2. Intermediate
¼b.VjehfM,V½

3. B.A. I/ B.Sc. I/ B.Com.I

ch-,- I@ch-,llh- I@ch-dke- I

4. B.A. II/ B.Sc.II/ B.Com.II

ch-,- II@ch-,llh- II@ch-dke- II

5. B.A.III/B.Sc.III/B.Com.III
ch-,- III@ch-,llh- III@ch-dke- III

DECLARATION AND OATH BY THE APPLICANT/ vH;FkhZ }kjk ?kks"k.kk ,oa 'kiFk
1. I, hereby, declare that the information given herein is correct.
eSa ?kks"k.kk djrk@djrh gWwa fd mi;qZDr fooj.k lgh gSA
2. I will abide by all rules/regulations for admission and attend the class/course as per requirement of the University.
eSa fo’ofo|ky; }kjk izos’k lEcU/kh lHkh fu;eksa dk ikyu d:Waxk@d:Waxh rFkk fo’ofo|ky; }kjk fu/kkZfjr U;wure d{kk@O;k[kku iwjk d:Waxk@d:WaxhA
3. Even if I qualify the admission test but fail to obtain minimum eligibility criteria in the qualifying examination, my candidature
for admission shall be rejected.
;fn eSa izos’k ijh{kk esa lQy gksrk gwWa] ijUrq vgZdkjh ijh{kk esa U;wure fu/kkZfjr vgZrk ekud vad ugh izkIr djrk gWw rks izos'k gsrq esjh vH;fFkZrk fujLr ekuh tk;sxhA
4. a- I will not indulge in any behavior or act that may be constituted as ragging.
eSa fdlh Hkh izdkj ds ,sls O;ogkj ;k d`R; esa lfEefyr ugha jgWwxk@jgWwaxh tks jSafxx esa lfEefyr gksA
b- I will be liable for punishment for indulging in any behavior or act that may be constituted as ragging
eSa fdlh Hkh izdkj ds ,sls O;ogkj ;k d`R;] tks jSafxx esa lfEefyr gks ds fy, ltk dk ftEesnkj jgwaxk@jgwaxhA
c- I have not been expelled or debarred from admission in any institution in the country on account of being found guilty of ragging.
eq>s jSafxx dk nks"kh ik;s tkus ij ns'k ds fdlh laLFkku }kjk fu"dkf"kr vFkok izos'k ls oafpr ugh fd;k x;k gSA
5. I have not been convicted in any criminal case and no criminal case is pending against me in the Court.
eSa fdlh vkijkf/kd ekeysa esa nks"kh ugh gWaw rFkk esjs fo:) dksbZ vkijkf/kd ekeyk U;k;ky; esa yfEcr ugh gSA
6. I have not been prevented from taking any examination on the basis of using unfair means at any exam.
eq>s fdlh Hkh ijh{kk esa vuqfpr lk/ku iz;ksx djus ds vk/kkj ij ijh{kk ls oafpr ugh fd;k x;k gSA

Signature of the Father/Guardian Date & Place Signature of Applicant

firk@vfHkHkkod ds gLrk{kj fnukWad ,oa LFkku vkosnd ds gLrk{kj
 n'keksRrj Nk=o`fRr@'kqYd izfriwfrZ gsrq vkosnu i=
1- fo|ky;@laLFkk dk uke@irk ---------------------------------------------------------------------------------------------
2- f'k{kk l= ------------------------------------------------------------------------------------------------------------------------------------
3- Nk=@Nk=k dk iwjk uke --------------------------------------------------------------------------------------------------------
4- tUe frfFk ----------------------------------------------------------------------------------------------------------------------------------- fo|ky;@laLFkku
5- gkbZLdwy mRrh.kZ djus dk o"kZ -------------------------------------------------cksMZ ----------------------------------- }kjk izekf.kr
6- vuqØekad ------------------------------------------------------------------------------------------------------------------------------------ Qks Vks fpidk,a
7- fyax ¼iq#"k@L=h½ ---------------------------------------------------------------------------------------------------------------------
8- firk dk uke o O;olk; -------------------------------------------------------------------------------------------------------
9- ekrk dk uke o O;olk; -------------------------------------------------------------------------------------------------------
10- fof/kd vfHkHkkod dk uke o O;olk; -------------------------------------------------------------------------------------------------------------------------
11- Js.kh ---------------------------------------------------------------- mitkfr ---------------------------------------------------/keZ -----------------------------------------
¼1- lkekU; 2- vuqlwfpr tkfr 3- vuqlwfpr tutkfr 4- vU; fiNM+k oxZ 5- vYila[;d½
12- iwjk LFkk;h irk --------------------------------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
13- i= O;ogkj dk iwjk irk --------------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
14- d{kk@ikB;Øe dk iwjk uke ------------------------------------------------------------------------------------------------------------------------------------------
15- ikB;Øe dh vof/k ------------------------------------------------------------------------------------------------------------------------------------------------------------
16- d{kk@ikB;Øe ds izFke o"kZ esa izos'k frfFk ---------------------------------------------------------------------------------------------------------------
17- orZeku o"kZ esa Nk=@Nk=k ds ikB;Øe dk o"kZ ---------------------------------------------------------izos'k frfFk ------------------------
18- d{kk esa izos'k dk izdkj ¼fu;fer lhV@LofoRr iksf"kr lhV½ ----------------------------------------------------------------------------------------
19- ekrk@firk@ifr dh lHkh L=ksrksa ls okf"kZd vk; -----------------------------------------------------------------------vk; izek.k i=
la[;k ---------------------------------------------------------------------¼;fn ekrk@firk thfor u gks rks fof/kd vfHkHkkod dh okf"kZd vk;½
20- vkoklh; Nk=@fnok Nk= ¼mYys[k djsa½ -------------------------------------------------------------------------------------------------------------------
21- Nk= ds cSad dk uke -------------------------------------------------------------------------------- 'kk[kk dk uke ------------------------------------------
[kkrk la[;k ----------------------------------------------------------------------------------------------------------¼tuin ds ckgj ds [kkrs vuqeU; ugha½
22- ikB;Øe gsrq Nk=o`fRr dh /kujkf'k ¼vadks esa½ ----------------------------------------------- ¼'kCnksa esa½ -------------------------------------------
23- ikB;Øe gsrq l{ke vf/kdkjh ls vuqeksfnr okf"kZd uku fjQ.Msfcy vfuok;Z 'kqYd
/kujkf'k ¼vadks esa½ ------------------------------------------------------------------------- ¼'kCnksa esa½ ----------------------------------------------------------------------
¼;fn iwoZ esa orZeku v/;;u vof/k esa dksbZ vUrjky@O;o/kku ¼xSi½ gks rks mldk iw.kZ fooj.k 'kiFk i= esa
layXu djsaA

?kks"k.kk&i=
ge ?kksf"kr djrs gS fd mijksDr lwpuk;sa lgh gSa] eq>s vU; fdlh L=ksr ls nwljh Nk=o`fRr;ka
izkIr ugha gks jgh gS rFkk eSa dgha Hkh lsokjr ugh gwaA
;fn dksbZ lwpuk ,oa layXu vk; o tkfr izek.k i= =qfV ik;h tk; rks Nk=o`fRr@'kqYd
izfriwfrZ dh lEiw.kZ /kujkf'k 18 izfr'kr C;kt lfgr okil dj nwaxk@nwaxh ,oa foHkkx esjs f[kykQ
leqfpr fof/kd dk;Zokgh ds fy;s Lora= gksxkA

ekrk@firk ds gLrk{kj@vxwaBk fu'kku Nk=@Nk=k ds gLrk{kj

¼ekrk@firk dh e`R;q dh n'kk esa fof/kd #i ls ?kksf"kr vfHkHkkod½
mijksDr lwpukvksa dk lR;kiu laLFkku Lrj ij dj fy;k x;k gSA

iz/kkukpk;Z@uksMy vf/kdkjh ds gLrk{kj

¼lhy o eqgj½
uksV&vkosnu i= Hkjus ds fn'kk&funsZ'k i`"B Hkkx ij vafdr gSA
 vkosnu i= Hkjus ds fn'kk&funsZ'k
1& vkosnu i= LoPN gLrfyfi esa fgUnh@vaxzsth esa Hkjs tk;A
2& Js.kh es vkosnu }kjk vuqlwfpr tkfr@tutkfr@vU; fiNM+k oxZ@vYila[;d tSlh fLFkfr gks vafdr
fd;k tk;A
3& vk; izek.k i= ewy#i esa layXu fd;k tk;A
4& gkbZ Ldwy izek.k i=] tkfr izek.k i= ,oa vU; 'kSf{kd i=ksa dh izekf.kr izfrfyfi vkosnu i= ds lkFk
layXu dh tk;A
5& vkosnu i= ij layXu QksVks bl izdkj izekf.kr dh tk; fd gLrk{kj dk vk/kk Hkkx vkosnu i= ij
vk;sA
6& Nk= dk cSad [kkrk mlh tuin esa gksuk pkfg;s ftl tuin esa laLFkk fLFkr gSA
7& vkosnu i=ksa ds lkFk layXu izek.k i=ksa esa tkapksijkUr ;fn dksbZ vfu;ferrk ikbZ tkrh gS rks vkosnd ds
fo#} oS/kkfud dk;Zokgh dh tk;sxhA
8& LFkk;h ,oa i= O;ogkj ds irs fuEu izdkj ls izfof"V;ka dh tk;%&
¼d½ xzkeh.k {ks= % xzke------------------------------------------ xzke iapk;r -----------------------------------------------iksLV vkfQl ------------------
fodkl [k.M ------------------------Fkkuk {ks= ---------------------------------rglhy ---------------------tuin -------------
¼[k½ 'kgjh {ks= % edku la[;k---------------------------- okMZ@eqgYyk-------------------------------------------iksLV vkfQl ----------------------
Fkkuk {ks=------------------------ 'kgjh fudk; -------------------------------rglhy ---------------------tuin ---------------
 vk; dk izek.k&i=
izek.k i= la0 -----------------------------------------------------
fnukad -------------------------------------------------------------------

;Fkk foHkkxh; ¼{ks=h; Hkwys[k fujh{kd½ Jh ---------------------------------------------------------------------------------------- ys[kiky

Jh -------------------------------------------------------------------------------- {ks= ------------------------------------------------------------dh tkWp fjiksVZ ds vk/kkj
ij izekf.kr fd;k tkrk gS fd Jh@Jherh@dq0 -------------------------------------------------------------------------------------------
iq=@iq=h@iRuh Jh ---------------------------------------------------------------------------------------- fuoklh xzke@eks0 --------------------------------------------
------------------------------------------ijxuk ------------------------------------------------------------------------------------------------rglhy-------------------------------------------
------------------------- ftyk ---------------------------- ds ekrk@firk@vfHkHkkod dh ekfld vk; #i;k vadks esa ---------------------------
'kCnksa esa --------------------------------------------------------------------------- gSA ftlds vuqlkj dqy okf"kZd vk; #i;k
vadks esa -------------------------------------#i;k 'kCnksa esa ---------------------------------------------------------- gSA budk@buds firk dk@buds
ifr ds vk; dk L=ksr ------------------------------------------------ gS tks fd 'kiFk i= esa n'kkZ;k x;k gSA ¼tSls flykbZ] d<+kbZ]
etnwjh] ukSdjh] d`f"k rFkk isa'ku vkfn esa ls tks Hkh ykxw gks½ rFkk vU; dksbZ 'kiFk i= ds vuqlkj gSA

gLrk{kj ys[kiky -------------------------------------------------------------------

gLrk{kj jk0fu0 --------------------------------------------------------------------- --------------------------------------------------------
rglhynkj

uksV & ;fn ekrk@firk@vfHkHkkod ljdkjh@xSj ljdkjh laLFkkuksa esa lsokjr gSa ;k lsok fuo`Rr gSa rks vk;
izek.k i= ds lkFk fu;ksDrk }kjk tkjh osru izek.k i= yxkuk vfuok;Z gSA