GURU JAMBHESHWAR UNIVERSITY OF SCIENCE & TECHNOLOGY, HISAR

Application Form (2010-2011)

(Last Date 20. 06. 2010 up to 5: 00 p.m.)
Registration No _____________
Received on _______________
Sign of the receiver __________
(TO BE FILLED IN BY THE OFFICE)

(TO BE FILLED BY THE CANDIDATES IN HIS/HER OWN HANDWRITING)

CAT-IIM-A Result :

CAT- IIM-A Roll NO. CAT Marks CAT Percentile

Date/Month/Year of CAT …………………………………………………….

1. (a) Name of the candidate in English (do not write prefix such as Shri, Mr., Dr. etc.)
Affix

Attested

(b) Name of the candidate in Hindi Photograph

2. (a) Father’s name in English (do not write prefix such as Shri, Mr., Dr. etc)

(b) Father’s name in Hindi

3. (a) Mother’s name in English (do not write prefix such as Smt., Mrs., Dr. etc)

(b) Mother’s name in Hindi

4. Date of Birth Date Month Year

5. Sex (Male/Female) ------------------------------

6. Nationality -------------------------------

7. Are you Kashmiri Migrant (write Yes/No) -------------------------------

8. Region (write Haryana/Other State) --------------------------------

9. Present Mailing Address:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
District______________ Pin _____________________ State ____________________________
Telephone No. (With Code)……………………….………Mobile No. ……………………………
E-Mail………………………………………………………………………….……………………

10. Permanent Address:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
District______________ Pin _____________________ State ____________________________

Telephone No. (With Code)……………………….………Mobile No. ……………………………

E-Mail……………………………………………………………………………………………

11. Write ‘Yes’, if Resident of Haryana (Domicile) or passed the qualifying exam from a University
located in Haryana, otherwise write ‘No’ _________________

12. Reserved Categories (for candidates belonging to Haryana State only): (Tick the appropriate
category)

a) Scheduled Caste ………………………………

b) Backward Class (Block ‘A’) ……………………….

c) Backward Class (Block ‘B’)……………………..

d) Ward of Deceased/ Disabled…………………….

(of Military Personnel)
e) Physically Handicapped…………………………

f) Ward of ESM……………………………………

g) Ward of Freedom Fighter………………………..

13. Academic Record :

Exam University/Board Year of Roll Subjects Marks Max. Percentage

Passing No. Obtained Marks of marks
Matriculation

10+2 or
Equivalent

Graduation

Post-
Graduation

Any other
14. Guardian’s Name and Address:

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Tel. No. …………………………………….. E mail……………………………………………..

Relationship…………………………………………………………………………………………

15. Area which you belong to: Urban/Rural

16. In case the form is downloaded from the university website the candidate is required to attach a

Demand Draft No. ……………………………………….. Dated…………………………………

Name of Issuing Bank………………………………………………………………………………

(Attach a Demand Draft of Rs. 300/- in case of General Candidates and Rs. 75/- in case of SC/BC/PH
Candidates of Haryana, in favour of the Registrar, GJUS & T, Hisar, Payable at Hisar)

17. Father’s/ Guardian’s Particulars:

a) Occupation ______________________________

b) Profession ______________________________

c) Nationality ______________________________

d) Annual Household Income (Rs.) ______________________________

Declarations by the Applicant:

1 I declare that entries made by me in this Application Form are true in all respects and in
case, any entry or information is found to be false, this shall entail automatic cancellation of
my admission besides rendering me liable to such action as the University may deem proper.

2 I note that my admission to the University and my continuance on its rolls are subject to the
provisions of the University and any other rules and instructions, which may be issued from
time to time. I shall abide by the rules of discipline and proper conduct, which may be
framed in this regard. I am fully aware of the law regarding ragging as well as the
punishment and that if found guilty on this account, I am liable to be punished
appropriately.

3 I undertake that I shall not indulge in any act of ragging.

(Signature of the Applicant)

Date __________________

Place __________________

Declaration by Father/ Mother/ Guardian:

Certified that all the information given above is correct

(Signature of Father/ Mother/ Guardian)

Place __________________

Date __________________