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DOEACC SOCIETY
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(An Autonomous Scientific Society of Department of Information Technology,
Ministry of Communications & Information Technology, Govt. of India)
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Aizawl Centre Paste here one
recent stamp
APPLICATION FORM FOR ADMISSION size photograph

(Please refer to instructions attached along with the application)

1. Name of the Course in which admission is sought :

2. Course Code in which admission is sought :

3. Name of the Candidate (In block letters)

4.i) Father’s Name:

ii) Occupation : ________________________________________________________

5.i) Mother’s Name:

ii) Occupation : ________________________________________________________

6. Guardian Name (If applicable): _________________________________________

7. Total Annual Family Income: _________________________________________

8. Present Address:

PIN -

Phone:

Mobile:
9. Permanent Address:

PIN -

Phone:
Mobile No :

10. Date of Birth : Day Month Year

11. Sex : Male Female

12. Category : SC ST OBC PH GENERAL

13. Marital Status : Unmarried Married

14. Community : Christian Sikh Hindu

Muslims Buddhist
Zoroastrians (Parsis)

15. State of Domicile :

16. Particulars of Examination Passed / Appeared :

Board/Univ. Examination Year of Subject taken/ Percentage Overall Class/

of Marks Percent- Division
Passed/ passing/ specialisation
(Math + sc.) age
Appeared Appearing

17. Whether candidate has availed coaching benefit under the scheme earlier?

Yes No

(Affidavit enclosed)
18. DECLARATION BY THE APPLICANT:
I hereby declare that all the information furnished by me in this application and in the
documents I have submitted in support of my application are true, complete and correct.
I also undertake that if I am selected, I shall abide by the rules and regulations of
DOEACC Centre, Aizawl as conveyed from time to time, failing which I may be expelled
from the Centre, and also that if I remain absent for more than 15 days without valid
reason or if I leave the course midway before completion, I will refund all fees and
expenditures due to me to the institution.

Date : Signature of the Candidate

Place:

19. DECLARATION BY THE FATHER /MOTHER /GUARDIAN

My son /daughter /ward __________________________________ is applying for
admission to DOEACC Centre Aizawl. In case of his /her admission to the Centre, I shall
be responsible for payment of all his/her fees and other charges incurred by the center if
he leaves the course without completion. I will also be responsible for his/her good
conduct and behavior during the period of his/her stay in the centre.
_______________________________________
_______________________________________
_______________________________________
Address of Parent/Guardian for Correspondence

Signature with Full Name

Relationship with the applicant : _______________________________________
_______________________________________
_______________________________________
Telephone Nos: ___________(O) ___________(R)
Place:
Date :
20. LIST OF ENCLOSURES:
a) Age Proof Certificate
b) Certificate & Mark sheets of Qualifying Examination passed
c) Community Certificate
d) Income Certificate
e) Affidavit
 AFFIDAVIT FORMAT

This is to state that, I, Mr/ Ms ________________________ S/o, D/o ___________________

___________________________ of _______________________________ have not availed of Coaching
Benefit under this scheme and that this is the first time I am applying for Free Coaching under the Scheme.
The above statements are true to the best of my knowledge and belief, and also hereby undertake that I will
forfeit all the benefits provided to me under the Scheme if any false information is found on my account.

NAME and SIGNATURE:

 ADMIT CARD FOR ENTRANCE TEST
Paste here one
recent stamp
(To be filled in by the candidate) size photograph

1. Name of the Course in which admission is sought:

2. Course Code in which admission is sought:

3. Name of the Candidate (In block letters as on the application form)

---------------------------------------------------------------------------------------------------------------------------------------------------------------------

(To be filled in by the office)

4. Roll No.
5. Venue of Entrance Test :……………………………………………………….
6. Date of Entrance Test :……………………………………………………….
7. Test Duration :……………………………………………………….

(Co-ordinator of Examination)
DOEACC Society, Aizawl Centre
Instructions For filling up of Application form for candidate belonging to Minority Communities
Item no. 1 Name of the course applied for should be written clearly on the space given.
(Please refer to clause 3.1 and 3.2 of the prospectus where name of the courses are given.)
Item no. 2. Code of the course applied for should be written clearly on the space given.
(Please refer to clause 3.1 and 3.2 of the prospectus where code of the course are given.)
Item no. 3 Name of the candidate should be written in capital letters. All characters including space and full
stop must be written separately in each box given.
Item no. 4 i) Name of the father of the candidate must be written in the same way of no. 2
ii) Occupation of the father of the candidate must be written clearly on the space given
Item No. 5 i) Name of the mother of the candidate must be written in the same way of no. 2
ii) Occupation of the mother of the candidate must be written clearly on the space given.
Item no. 6 Name of the guardian should be written only if Item no. 3 or 4 is not applicable (OR) for outstation
candidates.
Item no. 7 The total annual income of the family should be written. If income is from more than 1 member of
the family, all the income must be calculated.
Item no. 8 The present address of the candidate should be mentioned clearly as given in the prescribed
format along with phone nos.
Item no. 9 This must be filled only if differs from Item no. 7.
Item no. 10 Date, month and year of birth for the candidate should be written in the appropriate boxes given.
The day, month and year should be written in figures (Example- 15th January 2002 should be
written as 15-01-02).
Item no. 11 Tick mark should be given in the appropriate boxes given according to the candidate’s gender.
Item no. 12 Tick mark should be given in the given boxes according to the candidate’s category. If the
candidate belong to scheduled tribe category, tick mark is to be given in the box next to ST.
Item no. 13 Candidate should mention whether he/she is married. If so, tick mark should be given in the box
next to married.
Item no. 14 Community of the candidate should properly be mentioned. Put tick mark next to the given
community
Item no. 15 Candidate must mention the state where he belongs to.
Item no. 16 Details of examination passed or appeared starting from 10th standard should be mentioned.
Item no. 17 1 person can avail the benefit of this scheme of coaching only for once. If the candidate does not
availed coaching benefit under the scheme earlier, he/she should enclosed affidavit printed on
non judicial stamp of Rs. 10/- and submit along with the application form.
Item no. 18 The declaration is to be made by the candidate itself and therefore, candidate must read the
declaration carefully before signing.
Item no. 19 This declaration is to be made by the parents / guardian of the candidate, and likewise, the
parents/guardian should read the declaration carefully, and should be signed only if agreed.
Address, relationship and telephone nos. etc. should be specified at the space given.
Item no. 20 The necessary documents in Xerox copy should be enclosed, without which application form will
be rejected.

Concerned faculty may be asked if any query (other than above) arises.