SHAILABALA WOMEN’S COLLEGE MISSION ROAD, BUXIBAZAR, CUTTACK, 753001 APPLICATION FORM ADMISSION INTO 2 YEARS B.Ed. (Self financing) Session-2016-18 Photo FOR OFFICE USE ONLY ‘SIGNATURE OF THE VERIFYING OFFICER eee eee OO (FILL IN CAPITAL LETTERS) 1. Name: MARK FOR SELECTION 2. Father’s Name:, 3. Mother’s Name: 4.Guardian’s Nam 4, Date of Birth: wv . Marital Status: 6. Mobile No: ~ E Mail Id: oo . Present Address: 9, Permanent Address: C/o: PS. Dis C/o: Dist: Po: PIN Code. State: Po: PIN Code. State: 10. Nativity :(Odisha/West Bengal/Chhattisgarh/Jharkhand/Andhra Pradesh/ Other States)11. Reservation: a. Social -UR/SC/ST/SEBC b. Others- PH(VI/HI/OH)/Green Card/ Ex. Service man 12. Academic Details:~ sino | Boor/counct/University | pemret | a | et eel | : 1 HSC | | 2 a ] | 3 | +3 : - | a 6 | of | Any other - | | : | 13. Odia Studying status - Passed Odia as M..L up to HSC /equivalent level :- Yes /No 14. Hostel Accommodation -- Yes /No 15. Payment Details: Name of the Bank & Branch, Demand Draft No. Date. 16. Declaratiot I hereby declare that all the information furnished by me in this application form is true & complete to the best of my knowledge & belief .I undertake that entries made by me in this application form are final and binding on me Signature of Father/ Guardian Signature of Applicant Place: Place: Date: Date: LIST OF DOCUMENTS ATTACHED ALONGWITH THIS APPLICATION FORM. a) b) °) 4) e) f) 8)