Re-accredited at the ‘A’ Level (CGPA-3.28) by NAAC,
“STAR College” Scheme & Status by MST-DBT
A College with Potential for Excellence-CPE (Phase-III) by UGC,
Accredited at the G-AAA ‘A-1’ Level by KCG, Govt. of Gujarat / F./A. No.
15-16-______
“Yogidham Gurukul”, Kalawad Road, Rajkot-360 005 Ph.: (0281) 2562681, Fax: (0281) 2563952, email:
FOR OFFICE USE ONLY
Mr. / Ms. / Mrs. ______is admitted in M.Sc. ______at this College for the Academic Year : 2015-16Category: OPEN / SC / ST / SEBC / PH / MINORITY / OTHERS
DETAILS OF FEES PAID
Year / Semester / Fees Paid / Receipt No. / DateMerit / Mgt. / Govt. / Others
First / I
II
Second / III
IV
Checked By______Approved By ______
Clerk / AccountantPrincipal
APPLICATION FOR ADMISSION
M.Sc. ______(Pharma.Organic Chem. / Ind. Chem) Program
Important: If any information is not submitted or is found vague and/or incorrect, the application is liable to be rejected.
Category:OPEN / SC / ST / SEBC / PH / MINORITY / OTHERS
Academic Year: 2015-16
PERSONAL DETAILS
Name in full: Gender: M / F
Surname :First Name :
Middle Name :
Date of Birth:______In Words:______
Nationality: ______Caste:______Blood Group :______
CONTACT DETAILS
Residential AddressRegion:Urban Rural
Local:Permanent:
______
______
______
Pin Code: ______Pin Code: ______
Ph. No.: ( )______Ph. No.: ( )______
STD Code STD Code
Mobile : ______Mobile : ______
e-mail ID : ______
CO / EXTRA CURRICULAR ACTIVITIES
Achievements : Sports:______
Cultural: ______
Science Fair: ______Scholarship: ______
Seminar / Workshops Attended : ____________
Computer Knowledge : MS Office: Internet: Others: ______
N.C.C.-‘B/C’ Certi.: NCC Camp Attended : ______N S S :
DETAILS OF MEMBERSHIP
I Wish to join any of the following Forum / Cell as member during the course of my study :
Forum : Sports & YogCultural Science Creativity
Women EmpowermentSocial Work Value Education
CELL : Environmental Protection ICT & Website Earn while Learn
DETAILS OF FATHER / GUARDIAN
Surname : / Mr./Ms./Mrs.First Name :
Middle Name :
Relation with applicant :
Occupation of Father/Guardian :
Edu. Qualification of Parents: / Father:Mother:
Occupational Address:
Phone No. (with STD code): / Mobile :
Annual Income:Rs. In Lakhs / Rs. / 0-0.24 / 0.25-1.0 / 1.0-3.0 / 3.0-5.0 / 5.0-7.0 / >7.0
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ACADEMIC PROFILE
Name ofExamination / Medium
of Instruction / Name of
Board / University / Name of the
School / College / Dept. / Principle
Subjects / Year of
Passing / Marks / %
or grade / No. of
Attempts / Remarks
Obtained / Out of
S.S.C. (10th)
H.S.C. (10+2)
B.Sc. / F.Y.
S.Y.
T.Y.
P.G. Course
(Specify)______
Any Other :
COC, STCs etc.
ACHIEVEMENTS*:
Number of Seminars/Workshops/Conferences Participated: ______
Level: University: ______State: ______National: ______International: ______
Number of Articles Published: ______
Number of Seminars delivered in (a) Class Room: ______(b) Competitions: ______
Membership: ______
* (Please submit details in separate Annexure)
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UNDERTAKING
I, hereby, undertake that if admitted I shall conform to the rules and regulations at present in force or that may hereafter by made for the governance of the college and for the behavior and discipline of students and I also undertake that so long as I am a student of the college, I shall do nothing either inside or outside or outside the college that may interfere with its orderly governance and discipline.
I know that until I am issued Eligibility Certificate by Saurashtra University, my admission to the course will be Provisional.
I am also aware that my admission shall be cancelled if it is proved that I have concealed or furnished wrong information.
I shall be governed by rules and regulations of Saurashtra University and the college for my education.
Under any circumstances, I shall not be eligible for claiming the refund of any fees once paid by me to the college.
The interpretation of any term, word or clause of this form & prospectus shall, in case of dispute be defined and determined by the authorities of the college as final and shall be binding upon me.
I hereby submit that we have understood the matter of conferment of Autonomous status to the college and undertake to follow rules & regulations strictly.
Date: ______yours obediently,
Place: ______
Signature of the applicant
DECLARATION OF PARENTS / GUARDIAN / HUSBAND
In event of my son / daughter / wife / ward, Mr. / Ms. Mrs. ______being admitted to the institute, I undertake that he/she shall fulfill all aforesaid requirements and I shall also be responsible for his/her conduct and behavior and shall pay regularly all his/her dues to the college as determined by the authority.
I hereby submit that we have understood the matter of conferment of Autonomous status to the college and undertake to follow rules & regulations strictly.
______
Signature of the Parents / Guardian / Husband
Name : ______
Address: ______
______
Date: ______PIN: ______
Place: ______Phone No: ______
Email: ______
REQUIREMENTS:
No application for admission will be considered unless it is accompanied by one attested photo copies of the relevant certificates mentioned below:
(1)School leaving certificate.
(2)H.S.C. & B.Sc. Mark sheets.
(3)B.Sc. attempt Certificate.
(4)Authorized Reserve Authorized Category Certificate (if applicable).
(5)Certificates of any Academic, Cultural Activities, Achievement.
(6)Three Recent Passport size Photographs.
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