7/27/2019 ICR Application Form No

1/2

I N DI R A G A ND HI N AT I ON AL O PE N U NI V ER S IT YM A ID A N G A R HI , N E W D E L HI - 11 0 0 6 8

APPLICATION FORM FOR OPENMAT - XXXII, XXXIII, XXXI V, E N TR A N CE T E S T

IN STR U C TION S

1. R egionalC entr eC ode

2. ExamC entr eC ode

3. State

C ode

4. C ategor y

( Wr ite the r elevantcode in the box)

A1 - GENB2 - SCD 4 A - C r e a m y L a y er D 4 B - N o n C r e am y L a y e r

C3 - STD4 - OBC

5. N ationality( Wr ite the r elevant

code in the box)

A1 - Indian

B2 - Other s

6. Sex( Wr ite the r elevant

code in the box)

A1 - Male

B2 - F emale

( Wr ite the r elevantcode in the box)

7 . M ar i t a l S t a t u s

A1 - Mar r ied

B2 - Unmar r ied

8. Whether Minor ity:( Wr ite the r elevant

code in the box)

A1 Yes

B2 No

9. R eligion ( Wr ite the r elevant code in the box)

A1 HinduB2 MuslimC3 Chr istian

D4 SikhE5 JainF 6 Buddhist

G7 Par siH8 JewsI 9 Other s

10. Date of Birth 1 1. S o c i a l S t a t us ( Wr ite the r elevantcode in the box)

A1 Ex- ser vice manB2 War widowC3 Not applicable

12. Whether Kashmir i Migr ant

( Wr ite the r elevantcode in the box)

A1 YesB2 No

Dat e M ont h Year

13. Territory

A1 - URBANB2 - RURALC3 - T RIBAL

14. Employment Status

A1 - EmployedB2 - UnemployedC 3 - I G N O U R e g u l ar E m p l o y e eD 4 - K V S E m p l o ye e

15.a. Whether Physically

Handicapped:

A1 - YesB2 - No

1 5 . b . I f p h y s i c a l l y h a n d ic a p p ed(nature of disability)

A1 Hear ing Impair mentB2 Locomotor Impair mentC 3 V i s u a l I m p a i rm e n tD4 Reading DisabilityE5 Any other , Please specify

16.a. Are you registered with IGNOU( Wr ite the r elevant code in the box)

A1 YesB2 No

1 6 . b . I f y e s, w r i t e t he E n r o l . No . & P r o g ra m m e C o de i n t h e b o x e s b e l o w :

Enrolment No. Programme Code

17. Details of Scholarship being received if any

( a ) A n n u a l S c h o la r s h ipAmount

( Wr ite the r elevant code in the box)(b) D ept. O fferi ngSchol arshi p

A1 Govt. Deptt.B2 Other

(c) Family income (yearly)

Fold f rom here

18. Name of the Candidate

19. Name of Father/Mother/Husband ( str ike out w hichever hot applicable)

2 0 . ( a ) E du c a t i on a l Q u a l i fi c a t i on s( Which makes you eligible for the pr ogr amme)

Qualification C ode Year of Passing P e r ce n t a ge o f m a r k s

20. (b) Stream: (Cross (X) any one of the Appropriate Box only)

NON-GRADUATE( 10+2 or its equivalent)

Science Ar ts C ommer ce Engineer ing Other sGRADUATE

P O S T G R A DU AT E

21. Write Name & Complete Mailing Address( I n BL A C K B A L L P o i n t P e n o nl y )

N ame :

Addr ess:

P IN C OD E :

Enrollment No.:

22. For Office Use24. Photograph

2 3 . C a n di d a t e' s S i g n a tu r e

Affix your latestpassport size

photograph(4 cm x 5 cm) duly

attested byGazetted Officer

M WNH5 6 E F3 4 B S U0 1 2 A C D G I J K L O P Q R T V X Y Z97 8

1 . Ple a s e r e a d th e in s tr u c tio n s in th e in fo r ma tio n b r o c h ur e b e fo r e fillin g u p th is fo r m.2 . U s e B L AC K B A LL P O IN T P E N i n b o xe s u s in g E n gl i sh c a p it a l l e tt e rs o r E n g li s h n um e ra l s.3 . Do n o t ma k e a n y s tr a y ma r k s o n th is s h e e t.4 . D o n o t s t a p le , p i n , w r i n kl e s c r i bb l e , t e ar o r w e t t h i s s h e et .5 . W r i te i n C A P I TA L L E T T E R S o n l y w i th i n t h e b o x w i t h ou t t o u ch i n g t h e l in e s a s s h o w n i n t he S a m p l e b el o w.

FOR M N O. 1

FOR M N O.:

C O N TR O L N U M BE R :

7/27/2019 ICR Application Form No

2/2

25. Working Experience

D ur ation Years Months.

Employed in

(Cross (X ) any one of the A ppropriate B ox only)

Go vt./Pu bl ic Se cto r Se mi Go vt. P vt. Se cto r Self Employed

Annual Income

(Cross (X ) any one of the A ppropriate B ox only)

U p to 5 0 ,0 0 0 /-

1 .5 la c to 2 la c

5 0, 00 0 t o 1 l ac

A bove 2 lacs

1 lac to 1.5 lac

26. Addr ess for C or r espondence( D o not give Post Box N o. addr ess. Leave a blank box betw een each unit of addr ess like H ouse N o., Str eet N ame, P.O., etc.)

C ity

State

D istr ict

Pin C ode

27. Telephone N umber ( If any) with STD C ode/Mobile N o.

S TD C od e Telephone No. S T D C o de Telephone No.

28. Fax N o. ( I f a n y ) wi t h S T D C o d e

2 9 . E - m a il a d d r e ss / I D ( If any)

D E C LA R AT I O N B Y A P P LI C A NT

I hereby dec lare that I hav e read and unders tood the c onditions of eligibility for the program m e for whic h I s eek adm is s ion. I fulfilthe m inim um eligibility c riteria and hav e prov ided nec es s ary inform ation in this regard. In the ev ent of any inform ation being foundi n c o rr e c t o r m i sl e a d i n g, m y c a n d i da t u r e s h al l b e l i a b l e t o c a n ce l l a t i on b y t h e U n i v e rs i t y a t a n y t i m e a n d I s h a l l n o t b e e n t i t l ed t orefund of any fee paid by m e to the Univ ers ity

I hav e c arefully s tudied the rules of the Univ ers ity as printed in the Pros pec tus and I ac c ept them and s hall not rais e any dis pute infuture ov er the s am e rules .

Date: (Signature of the Applic ant)

I N S TR U C TI O N S F O R C A N DI D AT E S

1 . P l e a se s e n d y o ur A p pl i c a ti o n f o r m b y Re g i s te r e d / Sp e e d P o st t o t h e f o l l o wi n g Ad d r e ss :Regis trarStudent Ev aluation Div is ionI G N OU , M A I DA N G A R HI , N E W D E L HI - 1 1 0 06 8

t h2 . L a s t da t e f o r r e c e ip t o f f il l e d i n ap p l i ca t i o n fo r m f or X X XII O PE NM AT i s 1 5 July, 2012, for

t h thO P E NM AT - X XX I I I i s 15 D e c em b e r, 2 0 12 , a nd O PE N M AT X X X I V i s 1 5 J u l y, 2 0 13 .

3 . A p p l i ca t i o n f o r m r e c e iv e d af t e r th e d u e d a t e wi l l n o t b e a c c ep t e d .4 . P l e a se r e t a in p h o t o c o p y o f t h e fi l l e d a pp l i c a ti o n f o rm f o r fu t u r e r e f e r en c e .5 . F o r D e t a i le d in s t r uc t i o n s p l e a se r ef e r S t u d e nt s H a n d bo o k & P r o s pe c t u s.6. No doc uments are to be attac hed with this applic ation form .