Campus : Ghari, Awang Leikai,
Imphal West, Manipur - 795140
Application Number
KNOWLEDGE INNOVATION OUTREACH Paste passport size
photograph of
applicant.
ADMISSION FORM 2 Identical
photographs
along with the
Admission Form
INSTRUCTIONS
1. Form should be filled in Block Capital Letters in English Language with Blue ink only by the Applicant.
2. Incomplete application form will be rejected without any further communication.
3. Filling of the Admission form does not guarantee the acceptance of request for admission.
Signature of the Applicant
COURSE APPLIED FOR
SPECIALIZATION
SESSION AADHAAR NO.
(As per Secondary/ Senior Secondary Certificate)
NAME OF APPLICANT
DD MM YYYY
GENDER MALE FEMALE OTHERS DATE OF BIRTH
FATHER’S NAME
FATHER’S OCCUPATION MOBILE NO.
MOTHER’S NAME
MOTHER’S OCCUPATION MOBILE NO.
NATIONALITY INDIAN OTHERS (specify the name of the country) RELIGION
CATEGORY GENERAL OBC SC ST DIVYANGJAN
BLOOD GROUP MARITAL STATUS MINORITY
EMPLOYMENT GOVT. EMPLOYEE PVT. EMPLOYEE SELF EMPLOYED UNEMPLOYED OTHERS
PERMANENT ADDRESS MAILING ADDRESS
PIN CODE PIN CODE
CITY STATE CITY STATE
E-MAIL E-MAIL
MOBILE NO. MOBILE NO.
Any change in address should be immediately communicated to the University
HAVE YOU EVER BEEN DEBARRED BY ANY UNIVERSITY / BOARD ? YES NO
If yes, then attach the details of the same.
Signature of the Applicant
Academic Details (enclose self attested photocopies of the originals)
S.No. Name of Examination Roll No Semester/ Year Name of University/ Institution / Board % / CGPA
Work Experience Details (Furnish Latest two details) and submit work experience certificate
S.No. Name and Address of the Organization Total Experience in Years
LIST OF DOCUMENTS (SELF ATTESTED) TO BE SUBMITTED
1. All Previous Qualification Certificates
2. Photo ID
3. Address Proof
4. Caste Certificate
5. Aadhaar Card
DECLARATION BY THE APPLICANT
I hereby declare that information furnished by me at the time of admission is absolutely correct and has not been fabricated in any
sense. The enclosed copy of the documents are true photocopies of the originals. I have read and understood all the rules and
regulations of the university and promise to abide by them in true spirit. I also agree that for appearing in university examinations it
will be mandatory for me to maintain 75% attendance in every subject. I also agree that the university is empowered to cancel my
candidature/ admission/ forego the fee deposited/ claim for admission, in case of violation of university norms or if any information/
document submitted by me is found to be incorrect, misleading or counterfeited.
Date:
Place :
Signature of the Applicant
DECLARATION BY THE APPLICANT IN CASE OF LATERAL ENTRY
I hereby declare that I have already completed the formalities for year(s) of (Course Title)
from and agree to appear in
year(s) of examinations and also previous years mismatched paper, if any.
Date:
Place :
Signature of the Applicant
