2017224920

Form No.: __________

Admission Application Form (2017-2018)

(For Indian/NRI/PIO/OCI Candidates)
Paste your latest
(Note: Form to be filled in BLOCK LETTERS only) passport size
Colored
1. Program Applied for__________________________________________________________ photograph.
Please do not staple.
2. Give branch preference (if applicable) Having 3.5cm x 4.5cm
st
1 Choice_________________________
nd
2 Choice_________________________
rd
3 Choice_________________________
3. Campus Applied for Lucknow Shahjahanpur
Candidate's Signature
4. Hostel Accommodation required Yes No in the box

Candidate's Details
5. Name of the Candidate___________________________________________________________________________
(i) Contact Number____________________________________________________________________________
(ii) Email_____________________________________________________________________________________

6. Gender M F TG

7. Date of Birth D D MM Y Y Y Y
8. Place of Birth__________________________________________ 9. Domicile_____________________________

10. Nationality Indian (includes NRI) for PIO/OCI/foreign Nationals

Others (Specify)________________________________

11. Religion Hindu Muslim Sikh Christian Others (Specify:_____________)

12. Category General OBC SC/ST

Parent's Details
13. Father's Name______________________________________________ Contact No.__________________________
14. Mother's Name_____________________________________________ Contact No._________________________
15. Email ________________________________________________________________________________________

Address Details
16. Residence Status City/Town Village
17. Corresponding Address___________________________________________________________________________
_____________________________________________________________________________________________
City/District________________________________ State _____________________ Pin Code

18. Permanent Address______________________________________________________________________________

City/District________________________________ State _____________________ Pin Code

 19. Qualifying Exam status for Admission Appeared Passed
(for details of eligibility and qualifying examination, see Page 18-22 of the Prospectus 2017)
20. Qualification Details

12th/ Graduation Post

Class 10th Diploma (if any) (if any) Graduation (if any)
Name of
Program/Subjects
Board/
University
Name of College/
Institution & City
Year of Passing
Roll Number
Marks Obtained
Maximum Marks
Percentage (%)

21. DD Details
DD/Pay Order Number____________________Dated_________Amount_______________
Bank Name & Branch________________________________________________________
DD/Pay order of Rs. 1000/- to be made in favour of "Treasurer, Integral University", payable at Lucknow

Miscellaneous Information
22. How did you get to know about Integral University
Newspaper Internet Radio Magazine
Friends Relative Univ. Website Hoardings
TV Other (Specify) ___________________________________________
23. Have you previously applied for admission to Integral University? Yes No
If Yes, Course previously applied for ___________________________________________
Were you selected Yes No

Declaration
I certify that the particulars given by me in this application form are true to the best of my knowledge & belief. I have
carefully read the Prospectus of Integral University & agree to abide by the terms & conditions mentioned therein.
________________ ________________________
Date Signature of the Candidate
Documents to be enclosed (As applicable for the opted program)
Mark Sheet & Certificate of High School (Std X) or equivalent examination.
Mark Sheet & Certificate of Intermediate (Std XII) or equivalent examination.
Mark Sheets of all years of Graduation & Degree. (for admission to post-graduate courses only)
Referred by (if any)
Name____________________________________________ Email Id__________________________________
Employee Code____________________________________ Contact No._______________________________

COMMENTS OF REGISTERING OFFICER (For office use only)

Eligible Provisional Incomplete Not Eligible

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