REGIONAL INSTITUTE OF EDUCATION,

National Council of Educational Research & Training

AJMER - 305004
Application Form for admission, Session: 2011-12
1. Tick the Course applied for: B.Sc.B.Ed.
2. Subjects offered:

B.Ed.(Secondary)

Affix Recent
Pass Port Size
Photograph
here

/M.Ed.(Elementary) /M.Ed.(Advanced)*

B.Sc.B.Ed. 1. _____________ 2. _____________ 3. _____________

B.Ed.(Sec.) (Teaching Subjects) 1. _____________ 2. _____________
(See page 2 of Information Brochure for details)

3. Tick the Category to which you belong:

4. Tick if person with disability:

General/SC/ST/OBC/Physically Handicapped

Visually Handicapped

Hearing Impaired

(Attach Certificate)

Orthopedically Handicapped

5. Tick the minority group to which you belong: Muslim/Christian/Sikh/Parsi/Bhudhist/Jain

6. Name of applicant (IN CAPITAL LETTERS) ______________________________________________

izkFkhZ dk uke lqikB`; 'kCnks esa

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
7. Fathers name

_______________________________________________

8. Mothers name

_______________________________________________

9. Husband/Wifes name

_______________________________________________

10. Name of Guardian

_______________________________________________

11. Date of birth (Enclose Certificate)

_______________________________________________

12. Sex:
13. Nationality
14. State

M
F
_______________________________________________
_______________________________________________

15. Home Town

Nearest Rly. Station
Nearest Bus Stand
16. Permanent Address

______________________________________________________
Place:_____________________Railway:_____________________
Place:_____________________State:________________________
_____________________________________________________________
_____________________________________________________________
______________________________________ P I N - ____________

Telephone No. (with STD code)

___________________________ Mobile_____________________

17. Educational Qualification(s) (Attach Mark sheets year-wise)

S.
No.

1.
2.

3.
4.
5.

Examination

Sr. Secondary
or equivalent
B.A./B.Sc./ B.Sc.
B.Ed. Part I
Part.II
Part III
Part IV
M.A./M.Sc.M.Com.

Previous
Final
B.Ed.
M.Ed.

Year

Subjects
(Only Optional)

Board/University

Maximum
Marks

Marks
Obtained

Percentage
of marks

Div.

*Subject to the approval of the M.D.S. University, Ajmer

--------------------------------------------------------------------------------------------------------------------- ----------------------For Office use only
Category _____________
Percentage of Marks: 1. +2 level _________ 2. B.Ed./B.A./B.Sc. _________ 3. M.Ed./M.A./M.Sc. ________

Credit Marks________

TCM

1. Checking Officer _____________

2. Verifying Officer _____________

18. Name of the Institution and State from which the candidate has passed
I For B.Sc.B.Ed. candidates
Senior Secondary or equivalent
a. Institution _________________________________ b. State _________________
Name and place of the Examination Centre
(for Private candidates)
____________________________________________________________________
II For B.Ed. (Secondary) candidates
B.A./B.Sc. or equivalent
a. Institution _________________________________ b. State _________________
Name and place of the Examination Centre
(for Private candidates)
____________________________________________________________________
III For M.Ed. (Elementary) candidates
B.Ed. or equivalent
a. Institution _________________________________ b. State _________________
Name and place of the Examination Centre
(for Private candidates)
____________________________________________________________________

Declaration by the candidate

I hereby declare that all the information furnished in this application form is true and correct to the best
of my knowledge, and if anything found false, my candidature/admission may be cancelled.

Father's/Guardian's Signature

Certificate for wards of Employees of Central Government including Defence

Services/Autonomous Central Govt. Institution.
(For use by the candidate who has not passed qualifying examination from the Northern Region)
Certified that Shri/Smt. _____________________________ (Employees Name) Father/Mother/Husband/Wife of
Shri/Smt./Kumari _______________________________ (Name of Candidate) is an employee of Central
Government/Autonomous Central Govt. Organisation and his/her services are transferable throughout India.
He/she is presently posted as _________________________ (Name of Post) at _______________ (Place of
posting & State)

since ______________

Place: _____________________
Date: ______________________
List of enclosures:

Signature of Employer/Head of Deptt.

Designation with seal

1. ________________ 2. ____________________
4. ________________ 5. ____________________
7. ________________ 8. ____________________

3. ________________
6. ________________
9. ________________

Important Instructions. Before submitting the application, ensure that:

1. All relevant entries have been filled in completely and correctly.
2. The photocopies of the following certificates/mark-sheets have been self-attested and attached:
a. Caste Certificate (for SC/ST /OBC Candidates only)
b. Physically Handicapped Certificate, if required.
c. High School/Secondary Examination Mark sheet/certificate showing date of birth.
d. All mark sheets about which details have been given under the head-Educational
Qualifications
3. The candidate has signed it at the appropriate place.
4. Recent photograph affixed.
5. Employers certificate has been signed, if required.
In case the above conditions are not fulfilled, the application would be rejected.

Please fill in your mailing address on all the five address slips
Name :

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