Programme Applied for: P.G. & P.G.DIPLOMAS RCC/ Study Centre Code No………….
[MA – (HIS / ECO / PS / PA / SOC / ENG / TEL / HIN / URDU) M.Sc. – (MAT / BOT / CHE / PHY / ZOO / PSY / ENV.SCI.) / M.Com./ MBA / MLISC / BLISc / BPR / PGD- (MM/ BF / ES /WMMT / HR / WS), CPFN]
-------------------------------------------------------------------------------------------------------------------------------

Dr. B. R. AMBEDKAR OPEN UNIVERSITY
STUDENT SERVICES BRANCH
APPLICATION FORM FOR ACADEMIC COUNSELLOR FOR P.G. & P.G. DIPLOMA PROGRAMMES
1. Name: ………………………………………………………..…………
2. Father’s Name:……………………………………………………..…...
3. Date of Birth & Age: ………………………………………………….
4. Social Status (For statistical purpose only): …………………………
5. Study Center(Code No) proposed to teach ________ 6. Course(s) interested to teach (Subject)
Place :____________________ i)____________________________
District :____________________ ii)____________________________
7. a) Official Address with Phone No. b) Residential Address with Mobile No & E-mail I.D.:
______________________________ ___________________________________
______________________________ ___________________________________
______________________________ ___________________________________
______________________________ ___________________________________
8. Educational Qualifications (P.G. ONWARDS)
Sl.
No. Name of the Programme University / Institution Year of
Passing
Class /
Division
Percentage
of Marks
1
2
3
9. Teaching Experience:
Sl.
No. Name of the Institution Subjects taught Class Medium No. of
Years
1
2
3
10. Experience as Academic Counsellor in BRAOU (if any)
Sl.
No.
Study Centre PG / OTHER
Programme
Period Course(s) taught
(specify CODE / PLACE FROM TO the medium also)
1
2
3
11. Any other information (enclose separate sheet if necessary regarding Awards / Medals / Publications etc.)
12. Applicant should opt for one study centre only.
NOTE: .1 Please attach one set of attested copies of P.G. and above qualification certificates for office records.
2. Research Scholars and others must produce memorandum of marks of PG. They are also requested
to submit a certificate from their respective research supervisor.
Date: Signature of the Applicant
Place:
Signature of the Head of the S.C. Signature of the Principal / Head of the Institution
with Seal with Seals
PHOTO