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mination)
S.No.St{te/
1-tAppL
RollNo, Nallre (l:itcgor)' l)isabilitlTotalScore I
I I UP t9003678 I t446 Priyank Trivedi GEN 82.66GN
SL OI
2 UP t9050078 201r9 Sachin Bhardwaj oBC(C) 80.89CN
SL 02
UP t9067761 20639 Utkarsh Sharnra 80.40CN
SL 03
4 UP r9054473 18275 Utarajat Prasad CEN- '19.44 CNSL 04
l 5 UP t9011722 21885 Sawik Gupta GEN 79.39CN
SL 05
6 UP t 900 t941 21801 Upendra Singh Chauhan GENGN
SL 06
7 7 UP 19048451 2028r Garvita Singh SC 't8.67 GNSL 07
ti IJ UP l90l?011 23878 CDN 78.01GN
SL 08
UP t905t695 10949 Mukesh Kumar '17.56 GNSL 09
l0 l0 UP 19061715 21r8.1 Devesh Chaturvedi 7'7.55GN
SL IO
ll ll UP 20185 Vishal Negi CEN 7'7 .53CN
SL II
REGIONAL INSTITUTE OF EDUCATION, AJMERB.Sc.B.Ed, Part-I (PCM Group) 2019-20
Counselins Date :22-07-2019 at 10:00 AMProvisional Selected Candidate List of Uttar Pradesh State
(Gen. - ll OBC - 07 SC - 0,1 ST - 02)
Uttar Pradesh State Selected List General - 11
Uttar Pradesh State Selected List OBC - 07
Uttar Pradesh State Sclectcd List SC - 04
l9 I UP t9001E90 IH.18 Priyanka SC 67.12SC
SL OI
20 1 UP 19017621 2{085 Swapnil Singh 67 .07SC
SL 02
2l J UP 1904398.1 2105E Pankaj Cautarn SC 62.55SC
SL 03
4 UP r9014 r95 2Ut78 Bhawna Singh SC 6l .88SC
SL 04
t.i UP 19055910 I I 660 Varsha Khanvar s1- 52.94ST
SLOI
tl 2 UP le0,06 t_] 238i6 Rishika Anand SC 6t .23ST
SL 02
Againsr
ST
I UP t903219.1 56r Jagriti Chauhan OBC(NC) 16.64OBCSL OI
l-l 2 UP t9072373 21231 Uday Chaurasiya oBC(NC) 16.06OBCSL 02
l-1 UP 19065 t74 r l70l Pradumn Kumar Bind oBC(NC) 7 4.6OBCSL 03
t5 .l UP t9026371 213)7 Pralima Yadav oBc(NC) 't 4.3OBCSL 04
5 UP 19006.127 I t.159 Alok Sharma OBC(NC) '12.61 OBCSL 05
t1 6 UP t9022a11 11527 Amulya Kumar Maurya oBC(NC) 72.5tOBCSL 06
Iti UP t90609.16 24 n5 Shipra Singh Yadav OBC(NC) 72.21OBCSL 07
)2
Uttar Pradesh State Selected List ST 02
Page : l/3
GEN
78.95
Apeksha Singh
() SC
GEN
t9014213
I6
7
SC
I
\%
asthan State Selected List General - 05
Rajasthan State Selected l-ist OBC - 02
30 I RAJ 190{,1800 10813 Rachita Bakliwal OBC(NC) 79.63oBcSLOI
2 RAJ r9078765 I110? Govinda oBC(NC) 79.5OBCSL 02
asthan State Selected List SC - 0l
Provisional Selected Candidate List of Punjab State
(Gen.-02 OBC-01 SC- ST- )P ab State Selected Lisl General - 02
Pu ab Slrte Selccted List OBC - 0l
Provisional Selected Candidate List of Haryana State
(Gen.-02 OBC-0l SC- ST-)na State Selected List General 02
Haryana State Selected List OBC - 0l
t8 I HR 19008692 r9612 Rakhi OBC(NC '13.28 OBCSL OI
Provisional Selected Candidatc List ofDelhi State
(Gen.-0l OBC- SC- ST-)Delhi State Selected List General 0l
S.No.Stf,i./UT
Appl.No.
Roll\o. Nanre Cercgory DisabilityTotalScore
I Delhi ,9020068 19716 Harsh Jain CEN 79.7 4GN
SL OI
Roll \o. Name Cstegor] D isa b ililt TotalScore
S,No.Stat€/LT
AppLNo.
OBC( NC ) 8r.03CN
SL OI25 l t9077575 230t0 Bhumika Rinwa
10843 Tejasva Ajmera OBC(NC) 80.97CN
SL 0226 t90467.{0
Somitra Swamkar 80.36CN
SL 03RAJ 2234911
80. r9GN
SL 04RAJ 19050663 t0910 Tarang Rajvanshi2tt 4
oBC(NC) 80. r8GN
SL 05RAJ 19072057 22918 Komal Kaviat9 5
III
72.8 8SC
SLOISC19072652 ll3]6I RAJ32
TotalScore IDisabilityNanreStste/
trTAppl.
Roll No.S.\o.
76.51GN
SLOIoBc(NC)Nitish Kumar1s058728 17832I PBl3
73.05CN
SL 02Kiran Rana1901t695 t 77851 PBl1
62.84OBCSL OI
oBC(NC)Komal Kumarit9020372 0 732I PB-35
TotalScore IC*tegor! D isn b ililr-Roll \o.st3tc/
TTAppl.
S.\o.
CNSLOI
7 6.5oBC(NC)Garima Sainir9046610 24366I HRi6
15GN
SL 02GENAakash Yadav19036901 20067HRl?
Page t 2l3
I
RAJ
2 RAJ
GEN19006699
CEN
REGIONAL INSTITUTE OF EDUCATION, AJMERB,Sc.B.Ed. Part-I (PCM Group) 2019-20
Counselins Date : 22-07-2019 at 10:00 AMProvisional Selected Candidate List ofRajasthan State
(Gen.-05 OBC-02 SC-01 ST- )
lt
lvivel sinsr'
( attgor]
CEN
Name
2
(Gen. - 02
Stete/tiT
AppLNo.
Roll \o. Na me Cetegor) DissbilitlTotalScore I
I HP 19044674 t1791 Anupam Katoch GEN 78.88Pool
GN
SLOI
{l 2 r90731I5 19475 Saurabh Kukreti CEN 71.t2Pool
CNSL 02
Provisional Selected candidate List of Delhi, Jammu and Kashmir, uttarakhand'
Himachal Pradesh, Chandigarh State POOLED OBC Category - 02
(Gen. - oBC - 02 SC-
S.\o.Strte/ Roll \o. Name Categor! Disabilit]'
TotalScore
ll UKD r9010888 r9158 Pratibha Naik oBC(NC) 72.26
Pool
OBCSLOI
tl 2 HP t900 t302 28120 Kunjam Chaudhary oBc(Nc) 69.1
Pool
OBCSL 02
Provisional Selected Candidate List of Puniab' Haryana, Delhi, Jammu and Kashmir'
Uttarakhand, Himachal Pradesh' Chandigarh State POOLED SC Category - 02
(Gen. - oBC - sc-02 sT-)
S.\o.Strte/uT
Roll \o. Name Categor! DisabilityTotalScore I
1l I DELHI 19002080 21112 Prakshi Singh SC 73.95Pool SC
SL OI
.15 l HR 1900,1317 19557 Sachin Kumar SC 7 t.95Pool SC
SL 02
oBC- SC- ST- )
oBC- sc- sT-)
provisional Selected candidate List ofRaiasthan, Punjab, Haryana, Delhi' Jammu and Kashmir'
Uttarakhand, Himachal Pradesh, Chan<ligarh State POOLED ST Category - 02
(Gen. - oBC - sc- sT- 02)
S.\o.Strtc/
TJTRoll \o. Namc Cetegor! Disability
TotalScore I
J6 19022 r30 l0'108 Nisha Meena ST 69.5
l7 1 RAJ 19016817 19706 Mohit Kumar Meena 68.41Pool STSL 02
Provisional Selecled Candidate Lisl of PWD Category - 03
(Gen, - 03
S.\o.Statc/t'1'
AppL Roll \o. Name Calegory Dis.bilit]TotalScore
t3 I UP r9057740 24152 GEN 64.2PWDSL OI
2 UP 2.1t{.1 Atul Mani Mishra GEN s6.07PWD
SL 02
i0 UP I r 195 CEN 48.59PWDSL 03
Page:3/J
.10
UKD
REGIONAL INSTITUTE OF EDUCATION' AJMERB.Sc.B.Ed. Part-I (PCM Group) 2019-20
Counseline Date : 22-07-2019 at 10:00 AM
Provisional Selected Candidate List of Jammu and Kashmir' Uttarakhand,
Himachal Pradesh, Chandigarh State POOLED GEN Category - 02
ST-AppL
No.trr
I
APPINo.
AppL
Pool ST
SLOIRAJI
ST
Shiv Ratan Singh
19056912{9
Parth Upadhyayt90r 7666
REGIONAL INSTITUTE OF EDUCATION, AJMER(National Council of fducalional Research & Training)
(NAAC accredited with A+ Grade lnstitution of NCERT)
Performa for checking of original documents and depositing fees etc.Session 2019 - 2020
Progranrme
Reg./Appl. No......................................
l. Name ofStudent (ln Capital letters)
Mob.No
2. Mother's Name
Mob.No. .
3. Father/Guardian's Name
Mob.No
4 . Date of Birth
5, Category (GEN/OBC/SC/ST/PWD)
6. Aadhar Card No.(A photocopy must be attached)
7. State from which you have been
selected for admission
8. Residence Address
Affixlatestphoto
a?6ar'taNCGRT
9. Name of Home-Town
10. Nearest Railway Station
I l. Nearest Bus Station(For of Railway/Bus Concession)
12. Are you employed ?
(lfemployed, give the name &address of the Employer)
I 3. Teaching Experience (Certifi cate
to be enclosed duly contersignedby the lnspector of School/District Education Offi cerlBDO)
14. Narne ofthe Board/University last attended
15. Name ofthe lnstitution last attended.
16. In case you have already been enrolled in theMDS University, Ajmer please mention yourEnrolment Number
I 7. Whether Hostel accommodation is required?
18. Whether Police verification certitlcate is enclosed?
Yes / No
Yes / No
P.T.O.
1
19. Academic Records
Date : Full Signature of the student
Examination Passed Year DivisionMABXS Percentage
of marksobtained
SLrbject OfferedMaximum Obtained
Sr. Sec./lnter/+2
B.A./B.Com./B.Sc.
M.A./M.Com./M. Sc.
B.Ed./8.T./L.T.
M.Ed.
Other
FOR OFFICE USI,] ONI,Y
Original documents have been checked by me and found correct. Self Attested/Attested copies of
necessary documents along with the Original Transfer Certificate/College Leaving Certificate/Relieving
letterNo Objection Certificate from the Organization/lnstitution last served/serving are enclosed in the
original Application Form.
The student Ms./Mr. reported in the forenoon/
aftemoon of ........
CHECKING OFFICER
Fees may be accepted/not accepted.
CONVENOR
HEAD OF DEPARTMENT/CHAIRPERSON ADMISSION COMMITTEE
PRINCIPAL
Hoslel accomodation allowed/not allowed'
CHIEF WARDEN
FOR A UNTS SECTION USE ONLY
has deposited her/his fees amounting
to Rs.
Dated
Ms./Mr
vide Receipt No. .................... dated
Signature ofCashier
No.REGIONAL INSTITUTE OF EDUCATION AJMER
(National Council of f,ducational Research & Training)(NAAC accredited with A+ Grade Institution of NCERT)
Application for Hostel Admission
Session 2019-2020
q{S!.nraNC-RT
Affixlatestphoto
l. Name of Student
2. Aadhar No.
3. Mother's Name
4. Father/Husband/Guardian's Name
5. Permanent Home Address
6. Local Guardian and Address (ifany)
9. Fee Receipt No.: ... and Date......
l0.Name and Address of Persons to be contacted in emergency :
(t)
Mob.No
....Mob.No.... ......
....Mob.No..........
..... Mobile No. ........
(2)...... ..-.... Mobile No. .
ll.Declaration: (i) The above information is correct to the bestofmy knowledge and belief.
(ii) I have read and fully understood the rules and regulations ofthe hostel. I shall abide by them.
(iii) In case I fail in the University Main Examination, I shall immediately vacate the hostel.
Dnte
Date: Signature of H()l)
oRDI,]R
Ms.,Mr D/o W/o S/o. .. . . .
is hereby provisionally allotted Roorn No..........'...... in .........
Her/His admission is subject to her/his good conduct during the stay in the hostel'
Warden
.Hostel w.e
Chief Warden
ACKN WL[]I)GE 1'
I have occupied Room No........... of.............................. Hostel. I have taken possession ofthe following articles which are in good condition. The safe custody ofthese articles is my responsibility.
If I am founJ involved in any activity leading to damage to the hostel property, I will bear the expenses ofthe damage.
Table- l,Chair-1,Cot- I ,
Ceiling Fan- I ,
Complete Tube Light- I
Place: Ajmer
Signature of the Hosteler
Date:
This form should be submitted to the Hostel Clerk
with Phone/I,lobile No.
7. Programme/Course Admitted to
8. Date of Admission
Signature of the Student
Remarks of the Head of the Department : Recomrnended,4.Jot reconlnended for admission.
Name:
q{ S!:etr aNcGRT
REGIONAL INSTITUTE OF EDUCATION, AJMER(National Council of Educational Research and Training)
(NAAC accredited A+ Grade Institution of NCERT)
MEDICAL CERTIFICATE
D/o S/o Shri
Sex Height Weight
Affixlatestphoto
Age
Chest Measurement
Heart and Lungs: .........
Vision : Distance
Near:
Remarks (if any)
Color vision:
(lnability to distinguish between principal colours)
Congenital or other diseases:
Hearing
(Whether defective, must be corrected)
Pregrrancy (Female candidate): Yes / No
* I hereby certify that I have examined Ms./Mr. ......... ..
a candidate for admission to Four Year B.A.B.Ed./ Four Year B.Sc.B.Ed./ Two Year B.Ed./ Two
year M.Ed. Programme/ Diploma course of Guidance and counselling (DCGC) in the Regional
Institute of Education (NCERT), Ajmer (Rajasthan) and could not discover that sheftre has any
desease except
I do not consider that her/his will hamper her,/tris studies for the above mentioned
programme/course.
Date
Place
MEDICAL OFFICER
SEAL
* This certificate is to be given by a Medical
olMedical College/lJospital in the State.
Officer of a District Govt. Hospital or Superintendent
1
DECLARATION / UNDERTAKING
I, Ms./Mr. . D/o Wo S/o Shri .....in the light of Supreme Court judgment hereby solemnly declare that:
I have never indulged in any incident of ragging nor I will indulge in such kind of act in future. If I aur
found indulged in such activities ofragging, my admission will be automatically stand cancelled.
I have gone through all the rules and regulations ofthe lnstitute and I agree to abide by the same. I rvilladhere to all the rules pertaining to discipline of the hostel and the lnstitute. ln previous classes I $asnot involved in any act of indicipline. I shall not indulged in any indicipline activities leading to damagc
of HosteUlnstitute fumiture, CCTV Camera's etc. I also declare that I shall submit the hostel admissionform in the stipulated time. I shall not take any part in the unauthorised occupancy in the hostel room. I
also declare that I am not working in any govenrment/semi government/autonomous/private institution.
I was never charged of any misbehaviour/crime and neither I have been released on bail in matter ofany criminal act and no criminal case in pending against me in any Court of law.
No complaint/FlR has been lodged against me by any authority of previous Institution in which I
studied.
I am well aware ofthe University rules regarding 800/o attendance in each subject, which is compulsary,.
failling which I shall be debarred from taking the examination. If I remain absent without intimation to
the Institute continuously for l5 days or more from the Institute fbr any reason, rny narne shall be struckofautomatically from the students roll.
6. I shall attend classes regularly in the lnstitute and my admission can be cancelled if I conlinuouslyremain absent without the permission of Principal for a period of fifteen days or more. If, due toshortage of attendance, I am detained from appearing in the University Examination the responsibilitywould be of my own.
7. I hereby undertake that I shall participate in all the celebrations hosted by the Institute positively and
abide by all the rules and regulations of the Institute. ln case of my unsatisfactory conduct in and oroutside the Institute, my admission may be cancelled and I may be expelled from the Hostel and orlnstitute.
8. I declare that all the enteries in my admission form are true and correct to the best ofmy knowledge and
belief. In case anything is found wrong/incorrect my admission will automatically stand cancelled.
9. In case any relevant information is found to be suppressed by me, my admission can be cancelled at any
time.
10. I shall abide the rules and regulations mentioned in ordinance of Maharshi Dayanand Saraswati
Univeristy, Ajmer.
Date
S ignature ofthe student
Name
Class
My latest address is:-
I agree to abide by the declaration/undertaking given by my rvard.
Signature of the parents/Guardian
Name
Relation with the student
3
+
5
Emergency contact number
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(name of student) D/o S/o
do hereby undertake that in case my phasewise attendance is found short (as
per M.D.S.U., Ajmer norms) in R.l.E., Ajmer for the (Session/Semester) in
class my admission from this Institution or Hostel or both may
be cancelled.
Signature of the Student....
Name of the Student...............
Session 20......- 20......
I
I (name of parent) (Relation)
of_ (name of student) do hereby undertake that I am aware of
attendance rules (M.D.S.U., Ajmer) and cancellation of admission due to shortage in attendance.
In case the shortage of the attendance of my ward (name of
student), her/his admission may be cancelled from the Institute or Hostel or both.
Signature of the Parents/Guardian
UNDERTAKING BY STUDENT
UNDERTAKING BY PAREN'TS/GUAITDIAN
'ET 6I qITfiFI
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coPY of the LIGC RcgulatroD,s oh Curbtns thi: Nlenrca ol-llagtrnr.l rn Ilrqhur I:tIur:IrI ronIr I lnstltitt()ns. :i!1,
ll(!LLrlittromli I have, ln Particular. Pclused clatlsc -l ol llrs llslrrlJlr\t[:,.llrrl;tlrr urrarc as to \J]itt r()nslllulI..s rJtilrr!2) I have also. tn pantcuhr- P(ruscd clausc 7 and chlNc a I (, thc l(cgululrorrs und .rnr lrrllv a\\irr( i), llrt,pcnal and ftdmlnistr'lrtlve actron that is hablc Itr he takcn ugutnst lll\ \\itrd l cusc hr,sltc ts li)Un(l sullt\ ()j ,nabclting ragging. act ivel, or pJsst vel\ . or bctng l',art ol d c()n\ltrit{.\ I o |rr)nt()t c r irgs r r.rg
I) I hertrhv solemnly vcr rnd undrrtakc rhatl) N'11' ward rYill not indulg,.' in unr behavirrur or act lhat Irir! t)c coilstrtutcd irs [rg,{tn! lr]der cl,rusc i r)l titcRcgulations.b) i\'ly $'ard will not PilrtlctPalc ur or irbet (,r ploplgilrc througlr on\ lll ol .omnlsJlon or prlsjlrlrl lhirl ,nr\ l.crrxrstrtutcd as ragging undcr clilusc I oi'lhlj Rctulrtl()its'1) I hcrcby atirm lhat. il lbun(l tuillv oi riiltiiing, fltv *urti ts lrxhlc li)r punrslnnr,llt irccor(lrns tL).lir{r:r(. () I
of tlte Regulations, Nithout prc.lLtdrce to an\- othcr (norlnal u(tron llut ma\ hc taken Jralnst rlr- urrd unricr un\Fcnnl lalr or an! larv lirr thc timc berng rrr li'rcc,(l I helcbr'dcclarc tlut m\ tr:trd hts not hct'n crpcllcd or dclrurrcd Ilonr adnlssron rt.rnl insirtull(jn rn ther(,rntn'on acc(runt ()f [rerng tbund purll! Ol, Jbcttrng rrr bcrng pan r)l .r ron:,prrJc\ rrl pr0n'rrrrc rir,.:trn{ ar]rlliuther atlrm that, in casc thc tlcclaraltrtn rr lurtnr.i to hc rtnlrLrc. I l'rt urlrlrssion ol-rn\ rvirrd rs lr.lhl!, l.r h!calcellcd{\) Alongrrith tht' br'\( rrcnlronc(i p,rrnls I chr htrcrr rlcrlirrc tlr.rt
a) lv{v wtrd wrll ohcv lhc codc olcouluct ol'tirc tnstrttttc lntl th' rr,rr rnLltrige rn irnv Lrn,j ol'in-rLierlrlrrrt.iactivity whilc in and offlhc inslrtulror canrpus
b) My ward rvill bc solclv respunsrhlc lbr an-v kinrl ol lcc itlcnl,'rn rs lu! corrsc'd on occ(nurt ol thc atoyerncnli()ned clause ((r.a).
ANNEXURE IIAFFIDAVIT BY PARENT/GUARDIAN
l. Mr./Mrs./t\,1s. ( tirllname o f parent/guardian ) lbttEr/mother/guardian ofbecn Bdmitted to
, (tirll name ol'studenr rvith [.inivr'rsitv lloll Nurnbert . hrvincnanlc ol'(h€ instilutron) . havc recerved or dormlocded I
I)cclaretl this of_,nonlh of vear
S rg,r.lluru r)l dclx)ncnlNatnt'r\tldress
'I"clcphont/ Mobile No.vERl!-tcAl to)i
Vcri,ied &at thc contents ol'this allidavit are trur' to thu best t'l' my knorvlcdge lnd no part ol the allidar,rt rs lirlsr.'
and nothing has bccn concealed ol misst ted thcrcrn
Vcrifred at (placc) on this the (dar") oI'(month) . (-vear )
Solemnlyafl'umed and signed in my presence on lhrs theSignature 01' deponcnl.
ida\'r ol __ - (nlonth), _(-vear) aller reading the contents ol'tltrs allldavrt
OA I I I ( \)lv1l\llSSloNI:l(i'ote: lt is nandalor.y b suhuit this allilatt in the ob<.r't, /u,ot(tt, t_l .tl,tt {l(su( to t'tgist(1. litr lht
fotl hcon i ng uc*lc mt c s c s t t on.
-
il
ANNEXURE IAFFIDAVTT BY THE STUDENT
(full name ot student \\'ith lnslitutc Roll Nlrmber)sio tlo Mr./Mrs.
Solemnly aflirmed and signed in my- presence on dtis the --------(tlay.) oI*------(year ) afler reading the contents oflhis allidavit
.lt:tvlll.!lh('cI admrtted to name ol-tlre rnslitution) . havcreceived or downloaded a copy ofthe UGC Regulations on Curbrng the Menace of Ragging in HrgherFducahoml Imtitutions, 2009, (hereinafter called the "Regulatrons") carefully read and fiilly understood theprorrsron:i.co arned in the said Regulations.I ) I luve. rn particular. perused clausc 3 of tlre Rcgulatfi>ns and am awaro as to wlmt cbnstilut$ rng_sing
?l I have also, in partrcular. perustd clause 7 and clausc I I of th€ Regulatrom lnd am tully" x\rare ol thcpenal and administrativc action lhat is liable to bc takcn against mc in casc I am lbund gurlty of'ol abeltrograggng actively or p0ssively, or berng part ofa conspiracy to promote raggrng.:i) I trereby solemnly ave{ and undcnake th3la) I will not indulge in anv behavrour or acl that mav be constltuted as ragging undsr ulause 3 uf theRegulations.b) I will not participate in or abet or propagate tiuough any act of commission or onissron that ma\ be
constihned as fagglng under clause 3 ofthe Regulatrons4) I hereby aSrm that. iflbu[d ertilty oiragging, I arn Lable tbr punrshment tccordrng to clausq 9 I o, theRegulatrons. without prejudlce to anv other cnminal actron that nuy be taken agarnst mc undrr ln1 penal lar\, rrany law for the time being in force.5) I trcreby d*lare that I havc noi becn expelled or debarred liom adrnission in any rnslitution rn the sormtryolr irccount of being found gualty ol'. abelting or b€ing part ola consprracy Io prollrote' ra88rng. and furlher oliirmthat. in case lhe declaration is fornd to bc u rue, I am a*are that my admission is liable to be cancellcd.6) Along with lhe above mcntioned poinls I do herebv declare that
a) I wlll obsy the crxlc olconduct ofthe institute and do not indulge in any kincl of in-disciplined irctivitr,ryhi16 in aid offthe imtitution cirmpus.
b I will be solely responsible for 8ny kind of accrdenu mishup carrx'd on account ol'thc irhorc mentr()ni:d
clause (6.a).
Declared this
-&y of
-
month of vear.
S ignature of deponentNanre.
vl:k ;tc.,\t'l( )N
Vcnllud lhilt ths c(rnt(nts ol'thts alljdx!tl trc tru( t() lhc hcsl ()l rr\ knrrrvlcdue itnrl no part of lhc iltil(lll!rt tr lrl\\lrrnd nothrng has bcen corrcealcd trr ntisstatcd tlttrctn
vcrificd at -------------(placc) on this thc --*-----(da:-") of ------(month), ---".--(year )
Signalure of dcponent
month),
OAI I I (IONIiVISSION lill
Nole : lt is mandalory lo submit this afi&o-it in lhe abote lbrm t, i{vou desire to regislerJil the
torlhcoming acade,n i c sP ssion.
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