Application Form
Computer Study Centre
Year: 2017-2018
Head/Principal/Proprietor Proposed Coordinator
(Note: Read the New Study Centre Application Booklet- February 2017 before filling the application form.)
Single point contact details of the person from the college/institute for New Study Centre Application ProcessName of person:
Mobile No.:
E-mail address
1.0 Which Category of Computer Programmes you are applying for?
Category / Programmes / Answer / Student Intake capacity applied for
1.1. / B / BCA Degree / Yes/No / 60
1.2. / C / Diploma / Yes/No / 60
Certificate / No limit
2.0 Information of the Institute Applying for Study Centre
Appendix A – Supporting documents of point nos. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16
2.1. / Name of the College/Institute
2.2. / Address
2.3. / City/Town
2.4. / Tehsil
2.5. / District
2.6. / State
2.7. / PIN Code
2.8. / Telephone with STD Code / Office:
2.9. / Email Address
2.10. / Type of Institute (NGO/ Private/Trust)
Approval Number and Date? / No: Date:
2.11. / Affiliated to University/Board
Approval Number and Date? / No: Date:
Type of Affiliation / Temporary / Permanent
Expiry Date of Affiliation (if any)
2.12. / Affiliation with Government Agency / Yes/No
2.13. / Affiliation/Partnership with Private Training Institute / Yes/No
2.14. / Dealership / Yes/No
2.15. / Is the college/institute already a Study Centre of YCMOU for any other Programme? / Yes/No
If yes: Study Centre Code: ______
Programme Code(s): ______
2.16. / Name and distance of the nearest active YCMOU Study Centre (in km) offering programmes of School of Computer Science / Study Centre Code:
Study Centre Name:
Study Centre Address:
3.0 Information of Parent Organization (for example Trust, Society, Foundation)
Appendix B – Supporting documents of point nos. 3.8, 3.9, 3.10, 3.11, 3.12
3.1 / Name of the Parent Organization
3.2 / Address
3.3 / City/Town
3.4 / Tehsil
3.5 / District
3.6 / PIN Code
3.7 / Telephone with STD Code / Office:
3.8 / Legal status of Organization (Public Trust Act 1950/ Shop Act / Societies Registration Act 1860/Company Registration/ Government Body) / Status:
Registration No:
Date of Registration:
3.9 / Is the organization registered with charity commissioner office? / Yes/No
If yes, Registration Number and Date / Registration No: ______
Date of Registration: ______
If not, provide SHOP ACT details
3.10 / If Trust/Society/Foundation, name of the Chairman
3.11 / Number of Institutes run by the Parent Body
4.0 Information of the Principal/Head/Director/Proprietor of College/Institute
Appendix C – Bio-data of the Principal/Head/Director/Proprietor of College/Institute along with the supporting documents (certificate/marksheets from highest qualification till graduation)
4.1 / Name of the Principal/ Head/ Director/ Proprietor of College/Institute
4.2 / Residential Address
4.3 / Phone with STD Code / Office:
Residence:
4.4 / Mobile No
4.5 / E-Mail Address
5.0 Information of the Proposed Coordinator
Appendix D – Bio-data of the Proposed Coordinator of College/Institute along with the supporting documents (certificate/marksheets from highest qualification till graduation)
5.1 / Name of the person who will work as Coordinator
5.2 / Residential Address
5.3 / Phone with STD Code / Office:
Residence:
5.4 / Mobile No
5.5 / E-Mail Address
5.6 / Date of joining the Institute
5.7 / Educational Qualification (Enclose necessary true copies of certificates/marksheets)
5.8 / Experience (Enclose necessary true copies of certificates) / Teaching …………….. years
Professional …………..years
6.0 Details of Staff at the study centre
Appendix E – Bio-data of the teaching staff of College/Institute along with the supporting documents (certificate/marksheets from highest qualification till graduation)
6.1 / Number of teaching staff (fulfilling YCMOU criteria)
6.2 / Number of non-teaching staff
7.0 Recommendation Letters
Give the details, in the following table, of two well-known persons
(For example Bank Manager, Principal, Head Master etc.) who knows about your institute.
Attach recommendation letters from two persons mentioned below on their letterheads in Appendix-F
Name / Address / Designation / Phone
8.0 Details of Computers
8.1 / Provide the details as specified in Appendix-G
9.0 Details of LAN, Printers and other Peripheral Devices
9.1 / Provide the details as specified in Appendix-G
10.0 Details of Internet Account
10.1 / Name of Service Provider
10.2 / Type of account (Broadband / ISDN / Dial-up / Leased Line)
11.0 Details of Teaching Aids
No. / Name of the Equipment / Quantity
11.1 / Television Set
11.2 / LCD Projector
11.3 / Other Equipments (Specify)
12.0 Infrastructure details
Provide the infrastructure details as specified in Appendix-H
Total Carpet Area / sq.ft.
Photographs of the Institute (Post Card Size) / Yes/No
True copies of layout of the institute/building with dimensions / Yes/No
True copies of Ownership / lease / rent documents / Yes/No
13.0 Library
Provide the list of books, magazines, CDs, DVDs etc as specified in Appendix-I
13.1 / Total no. of books
13.2 / Total no. of computer related books
13.3 / Total no. of magazines related to computer
14.0 Financial Status
Give the details for the last financial year (Attach Audit Report of the college/institute for 3 financial years) Appendix J
Number of students enrolled / Total fees Collected (A) / Expenditure / Total Expenditure
(B) / Net Income
A-B
Total Faculty Salary / Total computer maintenance charges / Cost of Books purchased / Other (electricity/telephone/rent etc)
15.0 Details of Accreditation and Membership of other organization
Attach the true copies of the letters of Accreditation and Membership of other organization in Appendix L
15.1 / Provide details if your centre is accredited to some organization.
15.2 / Provide details if your centre has membership of some organization like CSI.
16.0 MOU
Attach MOU as per the details given in Appendix M
The information filled in the Application Form is true to the best of my knowledge.
Date: Seal of the Institute Name and Signature of
Head/Proprietor/Director
Check list of the documents
Check List of Documents (Study Centre should ensure that all the documents are attached to the proposal in the proper sequence as mentioned below with proper tags and tick appropriate cells in the following table and attach this page as the first page of proposal)
No. / Essential / Additional Documents / To be filled by InstituteIs document attached? YES/NO / To be filled by SC S, YCMOU
√ for YES and
× for NO / Remarks
(To be filled by SCS, YCMOU)
1. / DD attached
2. / DVD attached
3. / Covering Letter of College/Institute on its Letter Head
4. / Recommendation Letter of respective Regional Director, YCMOU’s Regional Centre
5. / Check list of the documents
6. / Study Centre Evaluation Form for New Study Centre
7. / Application Form for New Study Centre
8. / Appendix A: Supporting documents of point nos. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16
9. / Appendix B: Supporting documents of point nos. 3.8, 3.9, 3.10, 3.11, 3.12
10. / Appendix C: Bio-data of the Principal/Head/Director/Proprietor
11. / Appendix D: Bio-data of the Proposed Coordinator
12. / Appendix E: Bio-data of the teaching staff
13. / Appendix F: Recommendation Letters
14. / Appendix G: Computer Hardware and Software
15. / Appendix H: Infrastructure details, True copies of layout of the institute/building with dimensions, True copies of Ownership / lease / rent documents
16. / Appendix I: Library
17. / Appendix J: Financial Status
18. / Appendix K: Resolution of the Society or Trust of parent organization in the given format / provide true copy of Shop Act License
19. /
Appendix L: True copies of the letters of Accreditation and Membership of other organization
20. / Appendix M: MOUOn behalf of my Study Centre, I have ensured that all the documents are attached to the proposal in the proper sequence as mentioned above along with proper tags and have ticked appropriate cells in the above table.
Name of the Study Centre’s Head/Coordinator
Signature of the Study Centre’s Head/Coordinator
Committee Recommendation (To be filled by SCS, YCMOU):
Appendix-A
Supporting documents of point nos. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16
Appendix-B
Supporting documents of point nos. 3.8, 3.9, 3.10, 3.11, 3.12
Appendix-C
Bio-data of the Principal/Head/Director/Proprietor of College/Institute along with the supporting documents (certificate/marksheets from highest qualification till graduation)
Bio-data of proposed Study Centre Head
YASHWANTRAO CHAVAN MAHARASHTRA OPEN UNIVERSITY, NASHIK
Note: Before submitting verify the completeness of the form. Incomplete forms will not be entertained.
(A) Personal Information
Personal InformationName in English (Write name in CAPITAL LETTERS) / Last Name / First Name / Middle Name
Date of Birth
Address (office)
Taluka / Dist / Pin code
Address (residence)
Taluka / Dist / Pin code
Phone (Office) / Phone (Residence)
Mobile No. / e-mail
Known Language / English / Marathi / Hindi
(B) Educational Qualification
Education / Diploma/ Degree Title / College/University / Board / Main / Special Subject / % Marks / Grade & Class / Passing
Year
Under Graduate Diploma
Graduation
Post Graduate Degree
PG Diploma
M. Phil.
Ph.D.
Other
(C) Teaching / Professional Experience
Teaching at under Graduate level / yearsTeaching at Post Graduate Level / years
Industrial/Professional Experience / years
Total Experience / years
(D) Contribution for implementing the programmes
No. / Type of Work / Programme / Course / Year/Duration / University1 / Counseling
2 / Text Book writing
3 / Text Book Editing
4 / Syllabus designing
5 / Paper setting
6 / Item writing/editing
7 / Examiner
(E) Projects handled
No. / Project Title / Front end / Back end1.
2.
3.
4.
5.
(F) Specify Programming Languages taught by you
No. / Subject name / No. / Subject name1. / 2.
3. / 4.
5. / 6.
7. / 8.
9. / 10.
(G) Specify the YCMOU courses you are interested in for counseling (should not exceed 5 courses) – Refer the Prospectus for list of courses.
No. / Course Code / Name of Course1.
2.
3.
4.
5.
(H) Select all those activities where you wish to contribute
Development / Tick Mark / Counselling and Examination activities / Tick MarkTextbook / Counselling
Workbook / End Exam Conduct for Practical, or Project-Work
Audio Video Lecture / Central Assessment Programme
Question Bank / Paper Setting
I declare that above information is true to best of my knowledge. Attested photocopies of
relevant documents are attached herewith.
Date:
Seal/Stamp of Signature of Principal/
College/Institute/SC Head/Proprietor /Director
Appendix-D
Bio-data of the Proposed Coordinator of College/Institute along with the supporting documents (certificate/marksheets from highest qualification till graduation)
Proposed Coordinator Bio-data
YASHWANTRAO CHAVAN MAHARASHTRA OPEN UNIVERSITY, NASHIK
Note: Before submitting verify the completeness of the form. Incomplete forms will not be entertained.
(A) Personal Information
Personal InformationName in English (Write name in CAPITAL LETTERS) / Last Name / First Name / Middle Name
Date of Birth
Address (office)
Taluka / Dist / Pin code
Address (residence)
Taluka / Dist / Pin code
Phone (Office) / Phone (Residence)
Mobile No. / e-mail
Known Language / English / Marathi / Hindi
(B) Educational Qualification
Education / Diploma/ Degree Title / College/University / Board / Main / Special Subject / % Marks / Grade & Class / Passing
Year
Under Graduate Diploma
Graduation
Post Graduate Degree
PG Diploma
M. Phil.
Ph.D.
Other
(C) Teaching / Professional Experience
Teaching at under Graduate level / yearsTeaching at Post Graduate Level / years
Industrial/Professional Experience / years
Total Experience / years
(D) Contribution for implementing the programmes
No. / Type of Work / Programme / Course / Year/Duration / University1 / Counseling
2 / Text Book writing
3 / Text Book Editing
4 / Syllabus designing
5 / Paper setting
6 / Item writing/editing
7 / Examiner
(E) Projects handled
No. / Project Title / Front end / Back end1.
2.
3.
4.
5.
(F) Specify Programming Languages taught by you
No. / Subject name / No. / Subject name1. / 2.
3. / 4.
5. / 6.
(G) Specify the YCMOU courses you are interested in for counseling (should not exceed 5 courses) – Refer the Prospectus for list of courses.
1.
2.
3.
4.
5.
(H) Select all those activities where you wish to contribute
Development / Tick Mark / Counselling and Examination activities / Tick MarkTextbook / Counselling
Workbook / End Exam Conduct for Practical, or Project-Work
Audio Video Lecture / Central Assessment Programme
Question Bank / Paper Setting
I declare that above information is true to best of my knowledge. Attested photocopies of
relevant documents are attached herewith.
Date: Signature of Applicant
Forwarded through me for further necessary favourable considerations as COORDINATOR
Date: Seal/Stamp of Signature of Principal/
College/Institute/SC /Head/Proprietor /Director
For YCMOU use only
Approved and certified by
Director,
School of Computer Science
Appendix-E
Bio-data of the teaching staff of College/Institute along with the supporting documents (certificate/marksheets from highest qualification till graduation)
Staff Details: Give details of Full-Time Teaching Staff at the college/institute and Proposed Visiting Faculties (suitable for this programme) (Enclose the Faculty Bio-data in prescribed format given after the following table along with the true copies of the mark sheets and certificates. For Visiting Faculties attach the Acceptance Letters also.)
No. / Name of counsellor / Educational Qualification / Total Experience in Years / Telephone Number (Residence and Mobile) / Name of the course to be taught1
2
3
4
5
6
7
Date: Seal of the College/Institute Name and Signature of
Principal / Head/ Director/
Proprietor
Full-time / Visiting Faculty Bio-data
YASHWANTRAO CHAVAN MAHARASHTRA OPEN UNIVERSITY, NASHIK
Note: Before submitting verify the completeness of the form. Incomplete forms will not be entertained.