SCHOOL OF EDUCATION
BERHAMPUR UNIVERSITY
Bhanja Bihar, Berhampur – 760007, Odisha
2022 – 2024
To be filled by Candidate REMARKS (Office Use Only)
D.D No:…………………………………………………….
Date : ……………………………………………………… PASTE PASSPORT
SIZE PHOTOGRAPH
D. D Amount :…………………………….………………. (Self Attested)
Name of Bank :…………………………………………….
APPLICATION FOR ADMISSION INTO 2 – YEAR BACHELOR OF EDUCATION
(B. Ed.) COURSE
1. Name (IN BLOCK LETTERS) as per H.S.C : ………………………………………………………………
2. (a) Father’s Name :……………………………………………………..............
(b) Mother’s Name : …………..………………….……………………………...
(c) Guardian’s Name : …………………………………………………………......
3. Date of Birth as per H.S.C/Matriculation (In Figure ):
DATE MONTH YEAR
(In Words): ………………..………………………………………………………………………………...
4. Gender (Put a tick (√ ) mark in the box): MALE FEMALE OTHER
5. Nationality. : …………………………………………………………….
6. Whether the Candidate belongs to: Un-Reserved SEBC
(Put a tick (√ ) mark in the box): Schedule Caste Schedule Tribe
7. Whether Physically Handicapped: YES NO
(Put a tick (√ ) mark in the box):
8. Whether Ex-Serviceman: YES NO
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9. Educational Qualification (Enclose Self-attested Photocopies of all Certificates & Mark Sheets):
Name of the Stream Board / University Division Year of CGPA % of
Examination Passing or Marks in
SGPA Aggregate
10th (Matriculation)
+2 (Inter Mediate)
+3 (Graduation)
Any Other
10. Stream of Graduation:
1. Put a tick (√ ) mark in the box:
SCIENCE ARTS
COMMERCE OTHER
2. Name of the College/Institute last studied : ………………………………………………………………
3. (a) Permanent Address: (b) Correspondence//Present Address:
…………………………………………………..... ……………………………………………………..
…………………………………………………..... ……………………………………………………..
…………………………………………………..... ……………………………………………………..
…………………………………………………..... ……………………………………………………..
4. Mobile Number of Candidate : ………………………………………………...
5. Mobile Number of Parent/Guardian : ……………………………………………………...
6. E-Mail ID (IN BLOCK LETTERS) : ….…………………………………………………...@………………
Date:…....../………/2022 ______________________________________
(FULL SIGNATURE OF THE APPLICANT)
LIST OF DOCUMENTS ATTACHED (SELF ATTESTED XEROX COPY)
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Sr.No DOCUMENTS YES NO
1 Bank Draft as per requirement (In Original)
2 10th/ Equivalent Certificate & Mark sheet
3 Odia pass Certificate from competent authority if required
4 Intermediate or +2 Certificate & Mark sheet
5 Bachelor Degree or +3 Certificate & Mark sheet
6 Equivalence Certificate in case of any degree obtained from
University outside Odisha
7 Document showing CGPA/SGPA to Percentage (%) conversion
formula of Bachelor Degree. (if any)
8 Post Graduation Certificate & Mark sheet
9 Any other Certificate & Mark sheet obtained from last Institute
10 SEBC/SC/ST proof Certificate
11 Ex-Serviceman Certificate issued by Competent Authority
12 Disabilities (PWD) Certificate issued by Competent Authority
13 Residential Certificate issued by Competent Authority
14 Aadhar Card
Application form along with a set of all the above documents enclosed in an envelop,
“Application form for Admission in 2 year B. Ed. Course (Session 2022-24)” written on
top and addressed to “ THE PRINCIPAL, SCHOOL OF EDUCATION, BERHAMPUR
UNIVERSITY, BHANJA BIHAR, PIN – 760007” must be sent through
Speed Post/Registered Post before the last date of submission. The authority is not
responsible for any type of postal delay.
N.B : Application submitted by hand will not be accepted.
DECLARATION
I do hereby declare that, particulars furnished in the form are true to the best of
my knowledge and I shall abide by rules & regulations framed by the University from time
to time. I shall forfeit my candidature in case of fraud or misrepresentation of fact on my
part.
Date:………./..………/2022 ______________________________________
(FULL SIGNATURE OF THE APPLICANT)
N.B.: - (i) Application should be filled-in by the applicant in his/her own hand-writing.
(ii) Incomplete application will be summarily rejected.
(iii) Admission fee and Course Fee once deposited can not be refunded in any
circumstances.
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