Hkkjrh; tu lapkj laLFkku Indian Institute of Mass Communication v:.kk vklQ vyh ekxZ] ubZ fnYyh&110067 1. Aruna Asaf Ali Marg, New Delhi-110067 vkosnu i= & i=dkfjrk esa LukrdksÙkj fMIyksek ikB~;Øe (vaxt sz h) 2015-2016 Application Form - Post Graduate Diploma Course in Journalism (English) 2015-2016 Application No. fMekaM Mªk¶V dk O;kSjk Details of D.D. fMekaM Mªk¶V ua- D.D. No. “kqYd Fees (in Rs.) fnukad Date of Issue (DD/MM/YYYY) 2 0 1 5 cSd dk uke Bank Name 2. ojh;rk vuqlkj nks ijh{kk dsUæksa dk dksM 3. 1st Choice 2nd Choice vaxzsth i=dkfjrk ds f”k{k.k gsrq ojh;rk vuqlkj LFkku dk dksM fy[ks Indicate preference of IIMC centre for pursuing course in Journalism (English) 1st Pref. 2nd Pref. 3rd Pref. 4th Pref. A 1: Aizawl B 2: Amravati C 3: Dhenkanal D 4 : Jammu 5th Pref. 6th Pref. E 5 : Kottayam F 6 : New Delhi B 2: in English ¼dksM ds fy, ihNs ns[ks½a (Refer codes on the reverse) 5. vkosnd dk uke Name of Applicant 6. tUe frfFk Date of Birth 4. i=dkfjrk dk ek/;e Medium of Exam Choice of Examination Centre (DD/MM/YYYY) 7. fyax Gender 8. A 1 : Male B 2 : Female 1 9 0 0 11. firk@vfHkHkkod dk uke Father’s / Guardian’s Name 12. ekrk@vfHkHkkod dk uke Mother’s / Guardian’s Name 13. firk@vfHkHkkod dk O;olk; Profession of Father / Guardian 14. ekrk@vfHkHkkod dk O;olk; Profession of Mother / Guardian 15. ifjokj dh okf’kZd vk; Annual Family Income (In Rs.) 16. Nationality ukxfjdrk 9. oxZ Category A1: B 2: C 3: D 4: A 1 : Indian B 2 : NRI 10. foDykax General SC ST OBC PH A 1 : Yes B 2 : No Mobile No. eksckby ua- (please do not use .,/,(), etc) (a) Lukrd Graduation (b) A 1 : Passed B 2 : Appearing C 3 : Result Awaited 17. “kSf{kd ;ksX;rk dk fooj.k Educational Qualification details laLFkk dk uke Lukrd dk uke cksMZ@fo”ofo|ky; mÙkh.kZ dk o’kZ çfr”kr Board/University Year of Passing Percentage Name of the Institution Name of the Degree NA NA 10th 12th Graduation Post Graduate 18. 19. vuqHko Experience (if any) in dk uke Designation laLFkk dk uke Name of the Institution/Organization i= O;ogkj ds fy, viuk uke rFkk iwjk irk fy[ksa Write your Name & complete Mailing Address in BLOCK LETTRS dk;Z laikfnr 20. vkosnd ds gLrk{kj dsoy dkys ckWy IokbaV isu ls Signature of the Applicant (with BLACK BALL POINT PEN only) Name : Duties performed Address : Please Affix your Photograph here PINCODE E-mail ID funsZ”kksa rFkk dsUæ dksM ds fy, Ñi;k i`’B ds ihNs ns[ksa FOR INSTRUCTION & CENTRE CODE PLEASE SEE AT REVERSE vkosnu i= Hkjus gsrq fgnk;rs% INSTRUCTION FOR FILLING THE APPLICATION FORM: 1. pwafd ;g vkosnu e”khu }kjk i<+k tkuk gS A d`i;k bls vaxzsth esa gh Hkjsa A Please fill the form only in English as it is to be Machine Read. 2. QkeZ Hkjus ds fy, dsoy dkyh ¼L;kgh okys ;k ckWy IokbaV½ isu dk iz;ksx djsa A Use Black (Ink or Ball point) Pen only to fill the Form. ijh{kk dsUnzksa ds fy, dksM dksM CODE dsUnz dk uke CENTRE NAME AHMEDABAD K11 vgenkckn vkbZtksy caxykSj Hkksiky Hkqous”oj psUubZ xqokgkVh gSnjkckn tEeq dksph dksydkrk L12 y[kuÅ LUCKNOW M13 eqEcbZ ukxiqj ubZ fnYyh iVuk jk;iqj jkaph Jhuxj MUMBAI A01 B02 C03 D04 E05 F06 G07 H08 I09 J10 N14 O15 P16 Q17 R18 S19 3. CODE FOR EXAMINATION CENTRE AIZWAL BANGALORE BHOPAL BHUWANESHWAR CHENNAI GUWAHATI HYDERABAD JAMMU KOCHI KOLKATTA NAGPUR NEW DELHI PATNA RAIPUR RANCHI SRI NAGAR QkeZ Hkjus ds fy, vaxzsth ds cM+s v{kjksa o vadks dk gh iz;ksx djsa A bUgsa [kkuksa ls Nq, fcuk Hkjsa] tSlk fd uhps n”kkZ;k x;k gS A Fill the Form using English CAPITAL LETTERS and Numerals only with in the Boxes without touching the lines as shown below : A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 1 2 3 4 5 6 7 8 9 0 4. ,d [kkus esa ,d gh v{kj fy[ksa A ;fn ykxw u gks rks [kkus dks [kkyh NksM+ nsa A Write only one letter in one box. leave the box blank if not applicable. 5. [kkus esa igys izFke uke fQj e/; uke rFkk ckn esa miuke fy[ksa A uke ds chp esa ,d [kkuk [kkyh NksM+ nsa A Write your first name, middle name and then surname in the boxes. Leave one box blank between the names. 6. rkjh[k ds fy, Mh-Mh-@,e-,e-@okbZ-okbZ-okbZ-okbZ izfo’V djsa A Enter the Date in DD/MM/YYYY format wherever applicable. frfFk Date 1 7. 2 eghuk Month 0 5 o’kZ Year 1 9 9 5 viuk uke rFkk iwjk irk cM+s v{kjksa esa fy[ksa A Write your name and complete mailing address in block letters. 8. [kkuksa ds lkFk fn;s x, lacaf/kr dksMks dk iz;ksx djsa A tSls A1, B2, C3, D4 bR;kfn tks ykxw gksrk Write the Relevant Codes given beside the Boxes i.e. A1, B2, C3, D4 as applicable. 9. d`i;k vkosnu i= ds lkFk izek.k&i= LVsiyj] fiu ;k Vsx ls u tksMs A Please do not Staple, Pin or Tag Certificates to the Applicable Form. 10. d`i;k bl vkbZ-lh-vkj- izi= ds lkFk vokafNr fpUg u yxk;s A Do not make any stray marks on this ICR Form. 11. d`i;k bl izi= dks u xhyk djsa u eksM+s vkSj u gh bl ij ?klhV dj fy[ksa A Do not wrinkle, scribble, tear, wet or fold this Form. gks A