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UNIVERSITY OF GOUR BANGA

P.O. MOKDUMPUR, DIST. MALDA – 732 103 WEST BENGAL, INDIA

Phone: (03512) 223664 / 223666; Fax: (03512) 2235 568 E-Mail: registrar@ugb.ac.in, Website: www.ugb.ac.in

APPLICATION FORM FOR M. Phil. PROGRAMME (2 Years)

SESSION: 2015 – 2016 To The Registrar University of Gour Banga P.O. Mokdumpur Dist. Malda PIN – 732 103, W.B. Sir, I wish to apply for the M. Phil. Programme in the Department …………………………………… in

terms of your advertisement No.: ……../UGB/R-15, Dated-…………….. The requisite particulars are

furnished below:

1. Name in full (in block letters): Sri / Smt. / Km./Ms.

2. Name of Parents :

a) Father’s name with citizenship:

b) Mother’s name with citizenship:

3. Postal address in full to which communication should be sent (Please attach four self addressed unstamped envelope)

Tel./Cell No. Dist. PIN E-mail ID:

4. Date of Birth (Document must be enclosed)

5. a) Whether a citizen of India

b) Religion

Serial No: ………..

Cost of Form Rs. 500/- (Rs. 300/- for SC/ST/BC/PWD)

Affix Passport size photograph (Self Attested)

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6. Whether belonging to SC / ST / BC / PWD (Put tick mark) (Please attach a certificate in support of claim)

SC ST BC PWD

7. (i) Marital Status (Put tick mark) Married Unmarried

(ii) Name of the Spouse

8. Whether working in any Institution on whole-time/part-time basis (Write details)

9. If Yes:

(a) Name of the Institution & Address with Phone No.

(b) Nature of the post hold

(c) Date of joining

(d) Name & address of Employer

10. Subject

11. Area of Specialization

12. Language(s) Known

13. University Registration (Please mention the name of the University

No. Session:

14. Other Relevant Information (if any)

UNIVERSITY OF GOUR BANGA P.O. MOKDUMPUR, DIST. MALDA – 732 103

WEST BENGAL, INDIA Phone: (03512) 223664 / 223666; Fax: (03512) 2235 568

E-Mail: registrar@ugb.ac.in, Website: www.ugb.ac.in

Receipt cum Admit Card Received from Sri / Smt. / Km…………………………………………………………………… an application for admission

to the M. Phil. Programme in Arts/Commerce/Science (Please tick) and Department……………………………………..

Demand Draft No.:………………………; Issuing Bank: ……………..……; Date: ……………………

Date: ……………………...

………………………………. Signature of the receiving

assistant with seal

Serial No.: ………….. Cost of Form Rs. 500/- (Rs. 300/- for SC/ST/BC/PWD)

Affix Passport size photograph

(Self Attested)

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14. Whether prosecuting any course of study at present (If yes, then give details)

15. Academic records must be specifically mentioned. Self attested copies of mark sheet and certificate of all examinations should be enclosed.

Exams. passed Year University / College / School Marks with

percentage / class / Div.

Any other information

Secondary or Equivalent

Higher Secondary or Equivalent (10+2)

Graduation or Equivalent

Post-Graduation or Equivalent

Any other qualification

16. Whether qualified in NET / SET / SLET: (Certificate to be attached)

Subject Year of Passing

17. Research experience, if any (please attach separate sheet, if necessary)

18. Occupation if employed (name & addressed of the employer) (Pl. attach No Objection Certificate from the Employer)

19. Details of Bank Draft, if applicable

DD No. Name of the Bank Date Amount

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DECLARATION OF THE CANDIDATE

I certify that the above statements are true to the best of my knowledge. I shall abide by the terms and

conditions as embodied in the University Ordinances relating to M. Phil. Admission to M. Phil. (Session:

2015-2016) Programme is liable to be cancelled if any of the above statement is found to be incorrect.

Date: ………………………… Place: ……………….………..

……..……………………………….. Full Signature of the Applicant

N.B: All columns shall be filled-up properly. Incomplete form shall not be entertained.

Certification of the Employer

(Applicable in case of in-service candidates)

Certified that Sri/ Smt…………………………………………………………………. has been working on whole time

basis as …………………………………………. in/of……………………………………… at

………………………………………………………………………………….. since………………………………… .

The Institution has no objection if he/she carries out 2 Years M. Phil. Programme as regular candidate.

Date: …………………… …………………………………………… Signature of the Head of the Institution

with seal

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