College Code: - University of Mumbai

University of Mumbai, Mumbai
Institute of Distance and Open Learning (IDOL)
Application Form for Provisional Admission For the Academic Year 2011-2012
Important instructions for students :
a. Read prospectus carefully before filling the admission form ( )
b. Use black ink to fill the form. No overwriting. ( )
c. Fill in all fields in CAPITAL English letters only.
d. Mark � in appropriate box. ( �
Have you availed
Freeship
Scholarship
during Academic Year
2010-2011
Course ( ) :
(Write Below)
Applied Under
a) General Category
b) Reserved Category
16 Digit PRN / Roll No. and Year, if already given
Course Code :
(Write Below)
Exam Centre Name ( ) Semester ( I
Form No:
Year ( ( ) (1 st , 2 nd , 3 rd ) (Write
Below)
Semester ( II for
MCA
1 Old Students 2 Transfer Certificate 3 Migration 4 Eligibility 5 Enrolment
Write Code
The Director, Institute of Distance and Open Learning , University of Mumbai,
Sir,
I seek admission to the ---------------------------- course of the Institute of Distance and Open Learning, University of Mumbai. I am paying herewith
Rs. ����� being the amount of course fee, registration fee and other charges by Pay Order / DD No. ������
dated _______________________________Drawn on (Bank’s Name) _____________________________________________________________________
Branch __________________________________
1. Personal Information Section ( )
Name of the Student (in English):
Name of the Student as printed on
certificate
Previous Name of the Students:
(In case of Name change)
Reason for Name Change:
Willingly / After Marriage
Last Name
Marital Status
:
First Name
Unmarried
( )
Father’s/Husband’s Name
Married
( )
Date of Birth D D M M Y Y Y Y Gender : � Male � Female
Place of Birth Blood Group (with Rh) : Mother tongue
Religion : Citizen of (country name) :
Student’s location Category : � Rural � Urban � Tribal Area
Address
City/Town/Village :
Contact Details
Phone # 1:
Mobile number
STD Code
PIN :
Mother’s Name
Tehsil : District : State : Country :
Phone No
Email ID
Phone # 2
STD Code
Phone No
Is student a NRI/Foreign student? : YES / NO. If Yes Attached following documents Xerox for information.
Passport No, Validity, Country, Type of Indian Visa, Visa Validity, Visa/Residential Permit No., Date of Issue, Police Verification Report,
Sponsoring Agency : Privet Government Others
2. Legal Reservation Category Information Section ( )
Domicile of State Category : � Open � Reserved
If Reserved : � SC � ST � DT(A) � NT(B) � NT(C) � NT(D) � OBC � SBC
Caste :
If Physically
Challenged
� Visually
Impaired
�
Speech
Impaired
-
Sub-Caste : EBC PTC STC
�
Hearing
Impaired
� Mentally
Retarded
� Orthopedic
Disorder
Percentage of Disability
:
Please paste a passport
size (35 mm X 45 mm)
Photograph here,
Do NOT staple.
Photo should not
exceed the borders.
X
Student should sign
strictly inside the box
below only with black
ink.

Form No. :
3. Educational Details Section ( )
[Write ‘YES’ in the last column, against the qualifying examination, on the basis of which you are seeking admission to the said course. Write ‘NO’ in front of other
examinations]
‘Yes’ Please Note: 10 th & 12 th Details are mandatory if passed.
Last College Attended : Year : Roll No.:
Name of Name of Board / Name of School/College Date of Examination Passing Marks
Examination University State
Passing Seat No. (Last) Certificate Obtained
(MM/YYYY)
No.
Std 12 th
Other
� The details from the provisional statement of Eligibility (In the case of students from other than Maharashtra Boards)
Case No. Certificate No.
Date Month Year
4. Name of Subject and Codes for semester pattern courses select Sem 1 and Sem 2 subjects also.
Sr.
No
1.
2.
3.
4.
5.
Name of Subject
Ans. Lang.*
6. 12.
Sr.
No
7.
8.
9.
10.
11.
Name of Subject
Select the subjects as per respective course
�
*Answering Language: For M.A., M.A. Education English/Marathi/Hindi. For M.Com. English/Marathi For M.Sc., M.C.A., PGDFM, PFDORM : English
5. Student’s Work experience or Employment Details :
If Employed: Service Business Self Employment Profession other If student is not Employed Write Fathers Occupations and Income
Details
Occupation Students / Father : Experience in Years :
Annual Income Gap in education
6. Declaration by Student
,
Out of
Result
Ans. Lang.*
I hereby declare that, I have read the rules related to admission as given in the prospectus; and that the information furnished by me is true and
complete to the best of my knowledge. I am aware that my admission will be finalized by the University headquarters and that the admission fee will
not be returned or transferred to next year in any case. I further agree that the decision taken by the University and any change made in the rules
regarding admission from time to time will be binding on me.
Place :
Date :
Signature of the student :
Note: Student MUST retain photocopy of completely filled in admission form (both pages) for future reference. Available information in this form will
be required to activate his/her account on http://mum.digitaluniversity.ac portal.
http://mum.digitaluniversity.ac
Exam Center name
For M. A. M.Com.
Exam Center name
For M. Sc.
Exam
Center
name For
MCA Part I
Mumbai Panvel New Mumbai Lanja Mumbai Ratnagiri Thane Mumbai
Dadar Ratnagiri Khopoli Sawantwadi Dadar
New
Panvel
U.D.
Mathematics
(Vidyanagari)
Institute of
Andheri
Andheri Kankavli Uran Banda Andheri Khopoli
Science
Borli
Ghatkopar
Ghatkopar Pen Chiplun Mahad Ghatkopar Chiplun Panchatan
(Raigad)
Ratnagiri
Ulhasnagar Vasai Bhiwandi Karjat Ulhasnagar
Sawantwad
i
Deogad Vashi
Alibag New Panvel Pali-Sudhagad Alibag Mahad Dapoli Thane
Nagothane Ladvali