Application Form Number
(Please read instructions carefully before filling up the form. Candidates will be responsible for all errors / omissions) Course Code University Code 1 University Code 2
Pref 1
M A E C U J M C U K E
Pref 2M A C M C U T N
1. NAME OF THE CANDIDATE (As given in the School Certificate)
K A V I T H A A N A N D
2. FATHER'S NAME
A N A N D M A D H A V A N
3. DATE OF BIRTH 4. Gender 5. Category Please specify, if others
0 1 - 0 2 - 9 2 M - Male
F - Female
6. CONTACT INFORMATION (Land Line with STD Code) Mobile Phone Number
0 4 4 - 2 2 3 3 1 1 3 0 9 9 4 4 6 9 4 4 6 6
EMAIL ID
k a v i t h a @ y a h o o . c o m
7. DETAILS OF QUALIFYING EXAMINATION
Name of University / Board Year of Passing * Percentage **
H S C C B S E 2 0 0 9 6 0 . 4 5
U G U N I V O F M A D R A S A W T D 6 2 5 0
P G
*** Are you applying as a sponsored
If yes, name of the Programme
Candidate for M.Tech / M.Pharm programme √ S.No.
(for M.TECH. / M.ARCH.
STUDENTS)
8. ADDRESS FOR COMMUNICATION
U 3 5 S H A N T H I S T R E E T
A N N A N A G A R
CITY PINCODE
C H E N N A I 6 0 0 0 1 8
STATE T A M I L N A D U
0 0 8 1 0 6
10. DETAILS OF FEES PAID DATE 1 6 - 0 4 - 1 2
2 3 1 5 6 6 8 9 1 2
V E L L O R E
BRANCH CODE BRANCH CODE
0 0 1 4
CSIR/JRF GATE SCORE
Marks scored
To F
Year of Passing Marks scored Year of Passing
M. Tech A1
Yes No
Paste your recent photograph 4cm x 5 cm
Do not get the Photograph Attested
Do not staple the photograph
Name of the Company Designation From
M. Pharm Experience details
CENTRAL UNIVERSITIES COMMON ENTRANCE TEST (CUCET - 2012)
FOR ADMISSION TO PROGRAMMES IN CENTRAL UNIVERSITIES OF BIHAR, JAMMU, JHARKHAND, KARNATAKA, KASHMIR, KERALA, RAJASTHAN AND TAMIL NADU
CUCET - 2012
A1. SC, B2. ST, C3. OBC, D4.
PH, E5. Others
9. EXAMINATION CENTRE: On Line Centre Off Line Centre
*** Sponsorship by Central University of Rajasthan only - Please refer website for other details
** If results are not declared, mention your percentage upto last year / semester.
Note:* If results are not declared, mention "Results Awaited" (AWTD)
I submit that I will abide by the rules and regulations of the University. Signature of the Applicant
Please send back this form to University from which you have purchased this form or post it to the nearest participating Central University.
AMOUNT Rs. 250
TRANSACTION NO. (if the payment is made through IOB) UTR NO. (if payment is made through a bank other than IOB)
BRANCH NAME BANK NAME
BRANCH
I declare that all the particulats furnished above are true and correct.
