Application Form Form No: FAKIR MOHAN UNIVERSITY Space for attested Photograph VYASA VIHAR, NUAPADHI, BALASORE : 756020, ODISHA, INDIA Application form for FMU Research Eligibility Test Subject with specialization in which research is to be conducted ......................................... (FOR OFFICE USE ONLY) Category : General / SC/ST/PH/OBC ............................ Date of Entrance Test ..................................... Result .......................................................................... DEALING ASST. 1. Name of the Applicant (in capital letters) a) Permanent Address CHAIRPERSON, P.G. COUNCIL :...................................................................................................... :...................................................................................................... ...................................................................................................... ...................................................................................................... b) Correspondence Address :...................................................................................................... ...................................................................................................... ...................................................................................................... c) Mob. No :...................................................................................................... d) E-mail Id. :...................................................................................................... 2. Date of Birth: Date Month Year (as in H.S.C. Certificate) (in words ...........................................................................) 3. Sex : Male / Female 4. Marital Status : 5.Nationality .................... 6. Mother Tongue .....................................7. Religion................................. 8. Father’s Name : ......................................................................................................... 9. Mother’s Name : ......................................................................................................... FMU | Prospectus | 2013-14 Married / Unmarried 1 10. Academic Qualification : Degree / Diploma Board / University Passed / Appeared Maximum Marks Total Marks Secured Division / Class / Honours / Distinction Year of Passing Main / Optional Subjects offered HSC +2 Arts / Sc. / Com. +3 Arts / Sc. / Com. M.A /M.Sc./ M.Com / Other * Attested Copies of Marks sheets / Certificates of all examinations to be enclosed. 11. Mention whether SC/ST/OBC : ............................................... (Attach Certificate) 12. Bank Draft No. ........................................................... Issuing Bank ............................................................. Date ..................................... Amount .................................... .DECLARATION I do hereby declare that the particulars furnished in this form are true to the best of my knowledge and I shall abide by all rules and regulations framed by the University from time to time. I shall forfeit my candidature in case of fraud or misrepresentation of facts on my part. Date ...................................Full Signature of the Applicant 2 FMU | Prospectus | 2013-14