Rs. 5/-
MANIPUR UNIVERSITY LIBRARY
CANCHIPUR: IMPHAL
Sl. No.
Phone: 2220859
GRAM: MANIVARSITY
Pin: 795 003
(Membership form for use of the Scholars & Students only)
The Librarian,
Manipur University,
Canchipur, Imphal.
Sir,
I have admitted/registered myself in M.A./M.Sc./M.Com. (Previous/Final/Ph.D. in the Department of ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ … … ........ and I wish to become a member of the library. I have read the rules and regulations of the Library and I undertake to abide by them.
Particulars:
1. Name (in block letters) : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
2. Address during the course : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
(Leirak/Leikai) ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
3. Post Office/B.P.O. & P.S. : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
4. Permanent Address/Address after: ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ …
the course (Leikai/Leirak) : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
5. Father’s Name/Legal guardian’s name : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ … ........
6. Occupations of 5, P.O./B.P.O. & P.S. : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ … ........
7. Enrolment No. : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
8. Library Deposit/Library fee paid. : ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
Vide receipt No.
9. I was not/was a student of any other : ........ ........ ........ ........ ........ ........ ........ ........ ........ ................ department of the University . ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
10. I hereby undertake that in case I fail to return any of the books or library cards, I may be debarred from appearing at the Examination or my result may be kept withheld. I am also hereby bound to pay the cost of the books/cards.
Full signature of the student
Note: Original fee receipt, photocopy of T.D.C. marks sheet and 5 passport photographs of the M.A/M.Sc./M.Com. students and 7 passport photographs of the Research Scholar duly attested by the Head of the Department should be submitted.
In case he/she was a student, he/she should indicate the year and submit the Library Clearance Certificate issued to him/her.
11. Surety of the father/legal guardian:
Certified that, Shri ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
father of/guardian of Mr./Miss./Mrs. ........ ........ ........ ........ ........ ................ ........ ........ ........ ........ ........
of the Department of ........ ........ ........ ........ ........ ................ ........ ........ ........ ........ ................ ........ ........ ........ ........ ........
is responsible for the book(s) issued to him/her during his/her study in the University. I will deposit the cost of the book(s) within 5 (five) days of the receipt of the intimation from the University Librarian in case my ward fails to return the book(s).
Signature & address Signature of the
authenticated by ........ ........ ........ ........ ........ ........ Father/legal guardian
Date ........ ........ ........ ........ ........ ........
(Signature & address to be attested by a
Gazetted Officer)
12. TO BE CERTIFIED BY THE HEAD OF THE DEPARTMENT
Certified that Mr./Miss/Mrs. ........ ........ ........ ........ ........ ................ ........ ........ ........ ........ ................ ........ ........ ........ is a regular student/scholar of the Department of ........ ........ ........ ........ ........ ................ ........ ........ ........ and I recommended that he/she may please be given library facilities.
Head of the Department
Date ........ ........ ........ ........ ........ Seal
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13. FOR LIBRARY USE ONLY
Fee receipt verified Membership No. ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ four/two Reader
Ticket prepared as details given below:
Particular No. of Tickets Readers Tickets Sl.No.
Text book tickets 2
General Tickets 2/4
Reader tickets may be issued.
Librarian/Deputy Librarian
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14. FOR LIBRARY USE ONLY
1. Two/Four/Six Reader Tickets bearing Sl.No. ........ ......... ......... …… ......... …… deposited.
2. Clearance Certificate issued Ref. No. ........ ........ ......... ........ Date ........ ........ ........ ........ ......... ........ ........ received no. due certificate.
Full signature of the student