Application Form No.
PURVANCHAL INSTITUTE OF ARCHITECTURE & DESIGN
Plot no. AL-3, Sec-09, GIDA, Gorakhpur, U.P.
UPTU CODE - 766
FOR OFFICIAL REMARKS ONLY
COA CODE - UP31
INSTRUCTIONS
1. Please read the instructions in the Admission Prospectus-2013 before filling up this form.
2. Use BLACK BALL POINT PEN to write in the boxes using English capital letters or English numerals.
3. Do not make any stray marks on this sheet
4. Do not staple, pin, wrinkle, scribble, tear,wet or fold this sheet.
5. Write in CAPTIAL LETTERS only within the box, in your own handwriting without touching the lines
1. NAME OF THE CANDIDATE (as in candidate's class X marksheet or equivalent certificate - enclose photocopy)
2. MOTHER'S NAME (as in candidate's class X marksheet or equivalent certificate)
3. FATHER'S NAME (as in candidate's class X marksheet or equivalent certificate)
4. PHYSICAL STANDARD
Height
ft.
5. GENDER
Weight
inch.
kg.
7. NATIONALITY
Indian
6. CATEGORY
Male
GEN
ST
Female
SC
OBC
5. PROGRAM APPLYING FOR
Others
If Other
Specify
9. DATE OF BIRTH
(as in candidate's class X marksheet or equivalent certificate)
B.ARCH. UNDERGRADUATE DEGREE
6. ADMISSION CATEGORY
GBTU
D
JEE/AIEE
7. PREQUALIFYING TEST SCORE
M
Yes
-
Y
Y
Y
Y
No
(As applicable)
Name of Test
M
11. HOSTEL ACCOMMODATION
(Tick the relevant option )
NATA
-
D
for B Arch Program ONLY
Date of Test
Roll/ID #
D
D
M
M
Y
Y
Percentile
Y
Score
Y
.
8. EDUCATIONAL QUALIFICATIONS
It is mandatory to fill all details of educational qualification (as applicable) from class X onwards till last completed semester/year. if the system of marking of your school/college is on grading
pattern, convert grade into marks as applicable and fill in the respective columns. In absence of complete information, form will be rejected.
CLASS XII, candidates with Mathematics as one of subjects.
CLASS X
CBSE
ICSE
UP
OTHERS
Passing Year
CBSE
ICSE
UP
OTHERS
Passing Year
Board
Aggregate percentage of all subjects on
class XII marksheet (enclose photocopy)
.
Medium of instruction
English
Hindi
Others
8. GUARDIAN NAME
9. CONTACT NUMBERS
Country Code
Mobile Number
Landline phone number with STD(area) code
+
10. PARENTS DETAILS
Age
Qualification
Father
Mother
11. MANDATORY E-MAIL ADDRESS (Only in Capital Letters)
Profession
Organisation
Designation
12. Write your complete Correspondence address including
your name in English in Capital Letters with Black Pen.
(For all communication related to your admission)
14. PHOTOGRAPH
(Within the Box Only)
Write application Form No at the
back of a recent color
Photograph(size: 3.5x4.5cm)
& paste (do not staple).
Do Not Attest
Name :
)
Address :
)
13. SIGNATURE OF THE CANDIDATE
(Within the Box only)
State :
City :
Country :
Postal Code
(PIN/ZIP)
:
Write something about yourself...
15. Details of Payment of Form
BY DEMAND DRAFT
DD No.
MICR No.
-
Date :
-
(9digit number next to DD No. on the Demand Draft)
THROUGH ONLINE
Online Transaction No.
Receipt No.
Date :
16. SIGNATURE
I hearby certify that the information given in the Application (all relevant Forms) is complete and accurate.
I understand and agree that misrepresentation or omission of facts will justify the denial of admission, the cancellation of admission, or expulsion.
I have read, understood and do hereby consent to the Terms & Conditions for Admission as mentioned in Admission Prospectus 2013.
I have enclosed photo copy of class X marksheet or equivalent certificate.
Signature :
For
office use
only
Date :
Documents required for admission:
1. S.S.C. mark sheet
2. School leaving certificate
3. Valid NATA/UPSEE/AIEEE/JEE Score Card for architecture.
4. Caste certificate [if applicable]
5. Caste validity certificate [if applicable]
6. Gap certificate [if applicable]
7. Domicile or Nationality certificate [if applicable]
8. Migration certificate [if applicable]
9. Character certificate
10. Medical fitness certificate
NOTES
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You are advised to keep a photocopy of the complete application form.
Incorrectly filled, incomplete, unsigned forms & forms received after due date will be
rejected.
Forms once rejected will not be reconsidered & form cost will not be refunded.
You can not apply more than once for the same programme in one admission year.