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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

APPLICATION

FORM

FOR ADMISSION

Paste here one recent stamp 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) Fathers Name:

ii) Occupation

: ________________________________________________________

5.i) Mothers Name:

ii) Occupation 6. 7. 8.

: ________________________________________________________

Guardian Name (If applicable): _________________________________________ Total Annual Family Income: _________________________________________ Present Address:

PIN

Phone: Mobile: 9. Permanent Address:

PIN Phone:

10. Date of Birth

Day

Male

Female Month ST OBC

Year PH GENERAL

SC 11. Sex 12. Category : :

13. Marital Status : 14. Community :

Unmarried Christian Muslims

Married Sikh Buddhist Hindu

Zoroastrians (Parsis)

15. State of Domicile : 16. Particulars of Examination Passed / Appeared :

Board/Univ. Examination Passed/ Appeared Year of passing/ Appearing Subject taken/ specialisation Percentage of Marks (Math + sc.) Overall Percentage Class/ Division

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 : 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 : _______________________________________ _______________________________________ Signature of the Candidate

_______________________________________ 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