Fix your passport
sized photograph
within this box and
sign across it
Application Form
Remedial Classes
City Centre, Kanke Road
Ranchi-834008
Jharkhand
(opposite CMPDI)

Directions: Use Capital Letters & write clearly. Use separate Forms for applying to two or more streams of study.
C. For Class 12: In the % Marks column, give the Class 11 percentage marks of the subject you are seeking admission into.
For Class 11: In the % Marks column, give the Class 10 percentage marks of the subject you are seeking admission into.
A. PERSONAL
NAME
Ms/ Mr
Surname (Family)
First Name
Other Names
SEX
Male/ Female
DATE OF BIRTH
dd/mm/yyyy
CATEGORY
Gen/ SC/ ST/ OBC/ PH
NATIONALITY
Indian/ …………
RELIGION
(for statistical reports only)
PARENT/ GUARDIAN
Mr/Ms/Dr
Surname (Family)
First Name
Other Names
EMERGENCY CONTACT/s
Name of Person Phone/s Address B. COMMUNICATION INFORMATION
MAILING ADDRESS
PERMANENT ADDRESS
PLOT/HOUSE NUMBER
ROAD
TOWN OR CITY
DISTRICT
STATE
PIN CODE
PHONE NUMBER
CELL NUMBER
STD code: No: FAX:
EMAIL
D. Did you represent India or your State in any Game or Sport? Yes/ No
If Yes, name the Game or Sport …………………………………..………………………….....................
E. Important Scholarship, prize and other distinction obtained
Name of Award
Year
Reason for Award
The information given by me in this application is correct and true. I agree to follow all Rules & Regulations of the Central University of Jharkhand.
I also understand that if I am involved in any misconduct or ragging, the City Centre of the University shall take action that may include expulsion or/ and imprisonment as per UGC guidelines.
Date:
Place: Signature of Applicant
DECLARATION BY PARENT/ GUARDIAN
My ward, Ms./ Mr. …………………………………………………. shall abide by the University & its City Centre Rules at all times and the University may take any action it deems fit when Rules are violated. I shall not hold the University responsible once my ward is out of the City Centre.
My ward has
No Medical problem/s
Has a Medical problem/s of ………………………………………… (use extra sheet if needed)
Date:
Place: Signature of Parent/ Guardian
Attach photo copies of:
1. Mark-sheets of Final Examinations of Classes 11 and 10
2. SC/ST/OBC/PH/ Economically Weaker Section certificate if applicable
5. Certificate of conduct from Head of Institution
5. Certificate of representing India or State or District in any Sport or Game
Note: Originals will be required to be shown at the time of admission only.
DO NOT SEND ORIGINAL CERTIFICATES WITH YOUR APPLICATION. The University will not be responsible for any loss of original certificates. C. ACADEMIC
Name of Institution & University/Board
Subject/s
Degree/ Examination
Year
Marks %
Class 11:
Mathematics
Physics
Chemistry
Biology
Class 10/ O Level:
Mathematics
Physics
Chemistry
Biology