FOR OFFICE USE ONLY
Intimation No. :
Date Of Counselling :
Course Title:

Photograph
attested
by a Gazetted Officer
APPLICATION FORM
 Name of the Candidate
(IN BLOCK LETTERS)
Course applied for
Date of Birth
(As recorded in H.S.C. Certificate)
Nationality
Sex
Marital Status
Father’s Name
   
Permanent Address
  S.T.D. Code
  Tel. No (O)
  Tel. No.
  Fax
  E-mail
   
Present Address  (For Correspondence)
  Tel. No
  Fax
  E_mail
Name of the Qualifying
Year of Passing

Name of the Qualifying Examination .

Educational Qualification
Name of the Examnaton
Name of the School or College
Name of the Board Council/ University
Total Marks obtained/Total Marks
Percentage obtained
Division
       

UNDERTAKING

I S/o. At/Po-
Dist. Presently Paying Rs. in words towards course fee of D.Pharm / B.Pharm 1st Year / M.Pharm 1st semester. The subsequent instalments will be paid as per the following term periods in the form of D.D. drawn in favour of Gayatri College of Pharmacy, payable at Sambalpur.

I further undertake that if the installment due is not paid in proper time as specified, The management may impose late fine as decided from time to time. If the dues are till not realized I have no objection if my studentship is rejected or any action taken thereof. Further I undertake & declare that if the course is discontinued by me for any reason, than as per the decision of the Hon’ble Supreme Court of India in their judgement “Unnikrishnan Vs. State of Andhra Pradesh”, I will pay the total amount of course fee (4 years course fee for B.Pharm or 2 years Course Fee for D.Pharm or 4 semester course fee for M.Pharm) as mentioned above.
         
Date
Amount
D.D.No.
Receipt No. & Date