final form 1 - Indian Institute of Mass Communication

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Indian Institute of Mass Communication
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Aruna Asif Ali Marg, New Delhi-110067
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Application Form - Post Graduate Diploma Course in Advertising and Public Relations 2014-15
Application No.
Detail of DD
1. fMeakM Mªk¶V dk C;kSjk
‘kqYd Fees ( in Rs.)
fMeakM Mªk¶V ua
DD No.
fnukad
Date of Issue (DD/MM/YYYY)
2
0
1
4
caSd dk uke
Bank Name
1st Choice
ojh;rk vuqlkj nks ijh{kk dsUnªks dk dksM
2
. Choice of Examination Center
vkosnd dk uke
(dksM ds fy;s ihNs ns[ksa)
(Refer codes at the reverse)
2nd Choice
Name of Applicant
3.
4. tUe frfFk
Date of Birth
1
(DD/MM/YYYY)
5. fyax Gender
9
9. [email protected] dk uke
Father’s / Guardian’s Name
10. [email protected] dk uke
Mother’s / Guardian’s Name
11 [email protected] dk O;olk;
12 okf”kZd vk;
6.
ukxfjdrk Nationality
7. oxZ Category
8. foDykax
A1 : General
B 2 : SC
C 3 : ST
D 4 : OBC
A1 : Indian
B2 : NRI
A1 : Male
B2 : Female
PH
A1: Yes
B2: No
Profession of Father / Guardian
Annual Income (In Rs.)
13 nwjHkk”k ua
Telephone No.
(please do not use
/. etc)
(a)
(b)
A 1 : Passed
B 2 : Appearing
C 3 : Result Awaited
Lukrd
Graduation
[email protected]’ofo|ky;
Board/University
14 ‘kSf{kd ;ksX;rk dk fooj.k
mŸkh.kZ dk o”kZ
Year of Passing
Educational Qualification details
laLFkk dk uke
Name of the
Institution
izfr’kr
Percentage
Lukrd dk uke
Name of the
Degree
10th
12th
Graduation
Post Graduate
15 vuqHko Experience
in dk uke Designation Name
laLFkk dk uke Name of Institution
16. Ik= O;ogkj ds fy, viuk uke rFkk iwjk irk fy[ksa
Write your Name & Complete mailing Address In BLOCK LETTERS
dk;Z laikfnr Duties performed
17. vkosnd ds gLrk{kj
dsoy dkys ck¡y IokbaV isu ls
Signature of the Applicant
(with BLACK BALL POINT PEN only)
Name :
Address :
Please Affix
your
Photograph
here
PINCODE
E-mail ID
Mobile No.
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FOR INSTRUCTION & CENTRE CODE PLEASE SEE AT REVERSE
vkosnu Ik= Hkjus gsrq fgnk;rsa :
INSTRUCTIONS FOR FILLING THE APPLICATION FORM:
1.
;g vkosnu e'khu }kjk i<+k tkuk gSA d`i;k bls vaxzsth esa gh Hkjsa A
Please fill the form only in English as it is to be Machine Read.
2.
QkeZ Hkjus ds fy, dsoy dkyh (L;kgh okys ;k ckWy IokbaV) isu dk iz;ksx djsaA
Use Black ( Ink or Ball Point) Pen Only to fill the Form
ijh{kk dsUnzksa ds fy, dksM Code for Examination Centres
dsUn dk uke Center Name
dksM Code
ubZ fnYyh
y[kuÅ
iVuk
dksydkrk
xqokgkVh
Hkqous’oj
caxykSj
eqEcbZ
ukxiqj
vkbZtksy
Hkksiky
psUubZ
tEew
Jhuxj
dksph
A01
B02
C03
D04
E05
F06
G07
H08
I09
J10
K11
L12
M13
N14
O15
3.
NEW DELHI
LUCKNOW
PATNA
KOLKATTA
GUWAHATI
BHUWANESHWAR
BANGALORE
MUMBAI
NAGPUR
AIZAWL
BHOPAL
CHENNAI
JAMMU
SRINAGAR
KOCHI
QkeZ Hkjus ds fy, vaxzsth ds cMs v{kjksa o vadksa dk gh iz;ksx djsaA bUgsa [kkuksa esa Nq, fcuk Hkjsa] tSlk fd uhps n'kkZ;k x;k
gSA
Fill the form using ENGLISH CAPITAL LETTERS and Numerals only with in the Boxes without
touching the lines as shown below :
A B C D E F G H I J K L M N O P Q R Z 1 2 3 4
4.
5.
6.
8.
9.
10.
11.
8
,d [kkus esa ,d gh v{kj fy[ksaA ;fn ykxw u gks rks [kkus dks [kkyh NksM+ nssaA
Write only one letter in one box leave the box blank if not applicable.
[kkus esa igys izFke uke fQj e/; uke rFkk ckn esa miuke fy[ksaA uke ds chp esa ,d [kkuk [kkyh NksM+ nsaA
Write your first name than middle name and then surname in the boxes. Leave one box blank
between the names.
rkjh[k ds fy, [email protected],e-,[email protected] okbZ okbZ okbZ okbZ izfo"V djsaA
Enter the Date in DD/MM/YYYY format wherever applicable.
mnkgj.k / Example
1 2
7.
5 6 7
0 5
1 9 9 5
viuk uke rFkk iwjk irk cM+s v{kjksa esa fy[ksaA
Write your name and complete mailing address in block letters.
[kkuksa ds lkFk fn;s lacaf/kr dksMksa dk iz;ksx djsaA tSls A1, B2,C3,D4 bR;kfn tks ykxw gksrk gSA
Write the Relevant Codes give beside the Boxes i.e. A1, B2, C3, D4, as Applicable
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vkosnu i= ds lkFk izek.k&i= LVsiyj fiu ;k Vsi ls u tksM+s
Please do not Staple Pin or tag Certificates to the application form.
d`i;k bl vkbZ-lh-vkj- izi= ds lkFk vkokafNr fpUg u yxk;saA
Do Not make any stray marks on this ICR Form.
`
di;k
bl izi= dks u xhyk djsa u eksM+s vkSj u gh bl ij ?klhV dj fy[ksaA
Do not Wrinkle Scribble. Tear Wet or Fold this Form.
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