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UGC - NATIONAL ELIGIBILITY TEST JUNE, 2012 Print Copy of Application Form
(TO BE SUBMITTED TO THE TEST CENTRE IN DUPLICATE)

To be Filled by the Test Centre only

Roll No. 12870845

The particulars furnished by the candidate have been checked and verified

University Of Calcutta, Kolkata-700 073(12) UNIVERSITY TEST CENTRE

__________________________ CO-ORDINATOR (Signature)

Subject Code Centre Code

87 12 __________________________ OFFICE SEAL

NET Examination Detail

1. 2. (i) 2. (ii) 3. 4. Applied for Post Graduation Examination Subject of Post-Graduation Subject opted for NET Centre of Examination : : : : : JRF and Lectureship Both Appearing/Appeared in Final Year of PG Computer Science and Applications Computer Science and Applications University Of Calcutta, Kolkata-700 073(12)

Affix recent Passport size Photograph signed by the candidate and duly attested by the Head of the Deptt./Institution or Class I Gazetted Officer (DO NOT USE STAPLER OR PIN)

Personal Information
5. 6. Name (as per Hr. Sec. Matriculation Certificate Date of Birth (as recorded in matriculation or equivalent certificate) Sex Whether relaxation in age is sought 8. 9. 10. (i) 10. (ii) 11. 12. Category Visually Handicapped (V/H) / Physically Handicapped (PH) Father's Name Mother's Name Address for Communication Permanent Address : : : : : : : Mr. BISWARUP CHOWDHURY

: : :

01-10-1984 MALE No GEN Not Applicable Shri SWAPAN CHOWDHURY Smt. SHRABONI CHOWDHURY JUGNUTALA(MAHATAVPUR),MIDNAPUR TOWN, PASCHIM MEDINIPUR, WEST BENGAL, INDIA, 721101 FERURA,BISWANATHPUR,, PASCHIM MEDINIPUR, WEST BENGAL, INDIA, 721156

7.

Detail of Educational Qualification

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13. (a) 13. (b) 13. (c) 13. (d) 13. (e) 13. (f)

Examination Appearing/Passed : Name of the University : Year of Passing : Subject Offered : Specialization ( if any ) : Marks/Grade : Mark Obtained : Total Marks : % of marks obtained :

MCA West Bengal University of Technology NA NA NA NA NA NA NA

Passed M. Phil: No

Passed Ph. D.: No

14.

Detail of Fee Deposited

Name of the Bank Name of the Branch Branch Code Journal No. Deposit Date Amount : : : : : : : STATE BANK OF INDIA Midnapur Town 11385 009107663 25-04-2012 Rs. 450 West Bengal(26)

15.

The State/UT which you belong

Place: Date: Email:

Midnapur Town 26-04-2012 biswaruplearner@gmail.com

Phone No. (with STD Code) Mobile No.: 7501281228

Declaration
i) I, BISWARUP CHOWDHURY, hereby declare that all statement made in this application are true, complete and correct to the best of my knowledge and belief and in the event of any information being found false or incorrect or any ineligibility being detected before or after the test, my candidature is liable to be cancelled and legal action may be initiated against me. ii) I fulfill all conditions of eligibility regarding age limit, educational qualification etc. prescribed for the test. iii) I have gone through the conditions attached to NET and shall abide by the same. iv) I have deposited the required fee. v) I have noted that if my application is found incomplete/defective, the same is liable to be rejected summarily and no correspondence will be entertained in this regard. vi) I have read and agree with the Notification for the UGC NET including instructions, enclosures, check list and other relevant information.

Signature of Candidate________________

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