NATIONAL INSTITUTE OF RURAL DEVELOPMENT & PANCHAYATI RAJ (Ministry of Rural Development, Government of India) APPLICATION FOR ADMISSION TO PGDTDM4thBATCH(2015) (Recognised by University Grants Commission, New Delhi) Last date forreceivingfilled in ApplicationForm:28-11-2014 Application-cum-RegistrationForm ReadtheProspectus and Instructionscarefullybeforefilling up theapplicationform available in NIRD Website (www.nird.org.in/Distance EducationCell/PGDTDM/News &Events ) COURSE APPLIED FOR PGD-TDM Application No: CATEGORY: GEN/OBC/SC/ST/ PH D.D. No: To be filledby office 1. Name of theStudent (Same as in SSC/Matriculation Certifícate) in Capital Letters Paste here a recent Passport size Photograph duly attested by the Head of the Institute / College last attended or by a GazettedOfficer Mr./Ms./Mrs………………………………………………………………………………………. (a) Father’sName…………………………………………………………………………… (b)Mother’sName…………………………………………………………………………… 2. (a) PermanentAddress: 2. (b) AddressforCorrespondence …………………………………………………………………………. ………………………………………………………………………………… ………………………………………………........................... ………………………………………………………………………………... PIN……………….Phone/Mobile No………………. PIN……………… Phone/Mobile No……………………………. Email:………………………………………………………………………. 3. a) Date of Birth ………………………………………………………………………………………………………….. Date MonthYear b) Identification Marks 1)…………………………………………. 2)…………………………………………….. c) Nationality :Indian / Foreign……………… IfIndian, State of Domicile : …………………………………………………………… IfForeignNational, name of Country……………………………………………………… d) Gender:Male / Female Pin Stamp Size Photograph for ID Card Purpose 4. SpecimenSignature of theStudent (Signwithinthe box) 5.Particulars of academic record - pleaseattachattested copies of testimonials. Examination Board / College/ University Month& Year of Passing Subjects Studied and Passed Maximum Marks Marks Obtained Percentage Division 10th Class/ High School Degree (B.A./B.Sc./B.Com./ LLB.,/B.E./B.Tech./ B. Lib.) DECLARATION BY THE APPLICANT I, S/D of Sh……………………………….……………….. hereby declare thatalltheinformationfurnishedby me in thisapplication and in thedocuments I havesubmitted in support of myapplication are true, complete and correct to thebest of myknowledge and belief. Place: Signature of theCandidate Date: FOR SPONSORED CANDIDATES Application of Sh/Ms------------------------------- isforwardedforconsideration. Onhis/heradmission, full Programme Feewill be deposited. AuthorisedSignatory of SponsoringOrganisation Seal Note: Filled in applicationformalongwithDemandDraft (Rs. 500/-for Gen/OBC category -Rs 300/- forSC /ST/PHcategory) drawnin favour of NIRD-DEC-PGD-SRD, payable at Hyderabadand supported Xerox copies of theCertificates as detailedbelowmayplease be sent to Project Director, DEC, NationalInstitute Of Rural Development&PanchayatiRaj, Rajendranagar, Hyderabad 500 030 (Telangana) to reachonorbeforethedue date as mentionedabove. Attachonlyattested copies of thecertificates. Tickmarkthe boxes certificatesshould be presentedforverifi cation at the time of admission. againstthedocumentsattached. The original Secondary School Certificate (SSC) or High School Certificate (date of birth proof) Final Degree Certificate/Provisional Certificate SC/ST/ PH Certificate from competent authority Programme Fee Particulars : 1. General/OBC 2. SC, ST & PH - Rs. 10,000/- (to be paid in two equal installments) Rs. 9,000/- (to be paid in two equal installments)