CHAUDHARY DEVI LAL UNIVERSITY, SIRSA

CHAUDHARY DEVI LAL UNIVERSITY, SIRSA 

Exam Form For Supplementary /Ex-students December,2010 Examination 

(Incomplete Admission From will not be entertained) 

TO BE FILLED IN ENGLISH AND BLOCK LETTERS ONLY 

Roll No. Registration No. 

(To be allotted by the University) 

1. ( i ) Name of Course/Examination (ii) Part/Semester 

(iii) Course Code 

2. (i) Date of Birth 

Signature of Candidate (Within Box) 

Serial No. ….1 

Note: Name & Particular must be the same as have been shown in the certificate of 10+2 examination or in the 

DMC of Graduation. 

3. Appearing in Category Full (F) Reappear (R) Improvement (I) Additional Subject (A) 

(Attach Photocopy of DMC for eligibility) 

4. Examination Centre Code of Centre 

5. Name of Student in English (Block Letters) 

6. Father’s Name 

SHRI 

7. Mother’s Name 

SMT. 

8. (i) Address (Do not write name or Father’s Name) 

(ii) State to which you belong Contact no. 

9. Sex Code (M/F) 10. Medium English (E) Hindi (H). 

11. BC/SC/ST/Handicapped (PH), General (GE) or Blind (BL) 

12. Current Examination Subject Codes Subject / Papers in which appearing 

Subject 

Code 

PIN 

Affix Your 

Photo 

within box

13 The Reappear candidate must fill up the columne for each availed chance. 2 

(i) Information of Lower/Higher Examination/Reappear result of the same class. 

Name of Chance Year & Roll No. Result University 

Exam. availed Session 

14. Are you appearing in any other examination from this University or any other University simultaneously. Write ‘Yes’ or ‘No’ in the 

box 

15. If answer to Item No. 14 is ‘Yes’ write Particulars of all such exam. below. 

Name of Class University / Board Subject in which to appear 

Full Subjects/Re-appear / 

Improvement./Additional 

16. Have you ever been disqualified in any exam. or any UMC Registered against you, if yes, give detail. 

University/ 

Board 

Examination 

Year & 

Session 

Roll No. 

Punishment 

Awarded 

17. University Fee Receipt No./Bank Draft No. …………………….Dated…..………….Amount.………… 

18. For Improvement candidates only 

(i) Session & Roll No. for passing final . 

Examination 

(ii) Chance availed 

Final 

Previous 

Class Session RollNo. 

DECLARATION 

I solemnly declare that the particulars filled in by me in the above columns are 

correct and nothing has been concealed therein. In case of any discrepancy/concealment found therein, I shall 

be responsible for the consequences. 

Dated : …………….. 

Place : …………….. Signature of the Candidate 

ATTESTATION 

(Certificate to be signed by the attesting authority) 

1. I Certify that……………..………………S/o. D/o. Shri…………..………………..appeared in 

……………………….under Roll No………………..and failed/placed under Re-appear/passed 

(ii) He/She bears a goods moral character and has signed this form in my presence. 

Note : Attestation on behalf of the Attesting officer is not acceptable 

Full Name of the Attesting Officer ………………………… 

Designation & Full Address of attesting authority 

……………………………………………………………… 

……………………………………………………………… 

Place : Dated : Signature of Attesting Authority 

(With Seal) 

REMARKS BY UNIVERSITY REGARDING ELIGIBILITY 

Eligibility Checked from Result-sheet/Gazette/Original Documents (Please Tick Mark) as under: - 

Eligible Not eligible 

i)Name of Exam/Session …….ii)Roll No…………. i)Name of Exam/Session ………..ii)RollNo………… 

iii)Result………….. …….. iii)Result…………………… 

Eligible subject to Production of ……………………… Not eligible with reason……………………. 

Clerk Assistant Superintendent. Clerk Assistant Superintendent. 

. (Final Order, if eligible) Asstt. Register (if not eligible)

. 

PROVISIONAL 3 


ROLL No. SLIP 

Regn.No. ROLL NO. …………… 

(To be assigned by the Office) 

Name of Exam …………………………………………………. 

1. Admit (Name of the Candidate) …………………………….…... 

2. Father’s Name Shri ………………………………………….…. 

3. Mother’s Name Smt. …………………………………………… 

4. Centre of Exam. ……………………Centre No. ………………. 

5. Subject in which appearing 

1. …………….……..2...…..……………...3. .…….…………. 

4. …………………...5. …………………..6. ………………... 

6. Signature of the Candidate ……………………………………… 

(The candidate must sign. here before submitting this form to the University) Controller of Examination 

_____________________________________________________________________________________ 

1. Address for Correspondence 

Class……………...Roll No. ……………... 

Name……………………………………… 

Address…………………………………… 

……………………………………………. 

Phone No…..…………Pin…………..…… 


Class……………...Roll No. ……………... 

Name……………………………………… 

Address…………………………………… 

…..………………………………………... 

Phone No.……..………Pin………………. 

TO BE FILLED IN BY THE CANDIDATE 


(For Centre Superintendent) 

1. Roll No. ……………………………Name of Exam. …………………….. 

2. Regn. No. …………………………………………………………………. 

3. Name of Candidate ……………………………………………………….. 

4. Father’s Name Shri ……………………………………………………….. 

5. Mother’s Name Smt. ……………………………………………………… 

Space for latest 

Photo of the 

Candidate Male or 

Female duly 

signed and attested 

by the attesting 

authority 


Class……………...Roll No. ………………. 

Name……………………………………….. 

Address…………………………………….. 

……………………………………………… 

Phone No…..…………Pin…………..…….. 


Class……………...Roll No. ……………... 

Name………………………………………. 

Address……………………………………. 

…..……………………………………….… 

Phone No...……..………Pin………………. 

Space of Affixing 

Attested 

Photograph

REGN. No. Roll. No. 

Chaudhary Devi Lal University, Sirsa 4 

INFORMATION FOR COMPUTER USAGE 

TO BE FILLED IN ENGLISH (BLOCK LETTERS ONLY) 

1. Name of Examination Exam code 

2. Appearing in Category Full (F)/Reappear(R)/Additional (A)/Improvement ( I ) 

3. Examination Centre 

4. Name of Candidate 

5. Father’s Name: SHRI 

6. Mother’s Name SMT 

7. Correspondence Address 

Pin Code Contact No. Contact No. 

8. Sex Code 9.U.C.D.L. Reference No 

10. SC/ST/BC/Handicapped (PH), General (GE), Blind (BL) 

11. Papers Codes in 

which appearing 

M F 

12. Medium Previous Roll No. 

E H 

13. Signature of the Candidate 

Session of Last Exam 

RESULT 

(For Office Use Only) 

Signature of the attesting Authority 

(With Seal) 

14. Diary No. ………………… 15. Amount Received …………………………… 

Date……………………….. Univ. Receipt No. ……………..Dt. ………… 

16. Checked by University officials 

F R A I 

Affix unattested photo 

Signature of 

The Candidate

INSTRUCTION FOR GUIDANCE OF CANDIDATES 5 

Important Notes 

1. Must fill this form in your own handwriting accurately and with complete details. The particulates viz. 

Name, Father’s name should be as per Matric certificate. The correction will not be entertained at later 

stage. The result will not be declared, if the examination form is incomplete in any respect. 

2 Roll No. with date-sheet will be sent to the candidate(s) concerned by the University 10 days before the 

commencement of Examination. If a candidate does not receive Roll No. within this period, he/she 

should immediately write to the Superintendent (UCDL), Chaudhary Devi Lal University, Sirsa or 

contact personally with latest photo and requisite fee i.e. Rs. 50/-. 

3. In case of any wrong statement in the Examination Form or suppressing of the facts, the candidate will 

be responsible for consequences, which might lead to cancellation of candidature and other disciplinary 

action under the Rules and Regulations of the University in force, as the case may be. 

4. A Exam fee for Distance Education will be as under: - 

Re-appear Fresh 

(i) For Diploma in Art & Craft Rs. 1000+Rs. 200 continuation fee=Rs. 1200/- Nil 

For MBA/MCA Rs. 1000+Rs. 50 continuation fee= Rs. 1050/- Rs.1000/- 

(ii) Exam fee for other courses of 

Distance Education except M.Phil. Rs. 600+Rs. 50 continuation fee = Rs. 650/- Rs.600/- 

M.Phil courses Rs. 600+Rs. 50 continuation fee = Rs. 650/- Nil 

For Other Courses Rs. 600+Rs. 200 continuation fee= Rs. 800/- Rs.600/- 

( For the courses in which qualifying examination is 10+2) 

(BCA, BA Mass Comm., 1Year Diploma in Computer Sc.) 

B All regular courses(except B.Tech/M.Tech) Rs. 600+Rs. 50 continuation fee= Rs.650/ 

For Other Courses Rs. 600+Rs. 200 continuation fee= Rs. 800/- 

(For the courses in which qualifying examination is 10+2) 

B.Tech Rs. 700+Rs.200 continuation fee= Rs.900/ 

M.Tech Rs. 700+Rs.50 continuation fee= Rs.750/ 

Mercy chance fee 1 st additional mercy fee Rs.1000/- 

(In addition to above fee) 2 nd additional mercy fee Rs.1500/- 

5. All kinds of fee will be accepted through Cash with the receipt of University Cash Counter and through 

demand draft (DD) from Nationalised Banks drawn in favour of the Registrar, Chaudhary Devi Lal 

University payable at Sirsa (Haryana). 

6. Last date for submitting Examination form & fee: 

(a)Tentative date of Exam: 

Supplementary Exam 2010 

Regular 1 st December 2010 onwards 

Distance Education 20 th December2010 onwards 

(b)Submission of Examination form & fee: 

(i) Without late fee upto 15 th October 2010 

(ii) With late fee Rs.500/- upto 30 th October 2010 

(iii) With late fee Rs. 900/- upto 15 st November 2010

In case late submission of examination form due to late declaration of result for no fault of the candidate (s), 

no late fee shall be charged within 15 days from the date of declaration of result concerned. Thereafter, usual 

late fee will be charged as per schedule. 

7. Provisional list of Centres of Supplementary 2010 examination of Distance Education: 

( A ) Rohtak ( B ) Sirsa 

Centre at other places can be created if viable number of students and building is available at that place. 

6

CHAUDHARY DEVI LAL UNIVERSITY, SIRSA

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