Application for Admission

Note: Please read the instructions and form carefully before filling it. Mandatory fields are marked with '*' next to the title. Please write N/A if a particular field is not applicable.

Type of Admission:*	Academic Year
Mode of Admission:*	Session:*	Center Code:*

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Programme Applied For:*

Specialization:*

Select Term:*

(for programme list see ortibanda.in)

Personal Information

Name :* (based on the certificate of 10th examination)
Date of Birth:*	Age:*
Gender (M/F):*	Category:*
Nationality:* If others please specify:	Marital Status:*
Proof of Residence:*	Email:* Please enter your personal email id. Center email ids will not be accepted.

Correspondence Address:

Address Line 1 :*
Address Line 2 :
City :*
State :*
Pin(Zip) Code:*
Phone No :*
Mobile No :*

Check this box to copy same address below.

Permanent Address

Address Line 1 :*
Address Line 2 :
City :*
State :*
Pin(Zip) Code:*
Phone No :*
Mobile No :*

Check this box to copy correspondence address below.

Contact Details of Guardian

Guardian Name:*
Address Line 1 :*
Address Line 2 :
City :*
State :*
Pin(Zip) Code:*
Phone/Mobile No :*

Family Details

	Name	Occupation	Phone No	Mobile No	E-Mail Address
Father*
Mother*

Academic Information

Name of Qualifying Examination*	Month & Year*	Percentage*

Educational Qualification

Examination	Stream For example B.Sc maths/B.Tech/B.A/BRT	Name of the School / College and Board / University	Year of passing	Subject Studied	Marks Obtained	Maximum Marks	Percentage
10th*
12th
Graduation
Post Graduation
Other Educational Qualifications

Awards and Achievements (if any) :
Participation in Extracurricular Activities :

Employment History

Work experience : Yes No

If yes then Total Experience
Years: Months:

Payment Mode:*	Bank Name:*	DD Number:*	Amount*	DD Date:*
			Rs

Declaration

I hereby certify and declare that the information given in the Application is complete and accurate to the best of my knowledge.
I understand and agree that misrepresentation or omission of facts will justify the denial of admission/cancellation/expulsion.
I abide to all the terms & conditions of the University