Page 1 of 4

UNIVERSITY OF GOUR BANGA

Serial No: ..

Cost of Form Rs. 500/(Rs. 300/- for SC/ST/BC/PWD)

P.O. MOKDUMPUR, DIST. MALDA 732 103

WEST BENGAL, INDIA
Phone: (03512) 223664 / 223666; Fax: (03512) 2235 568
E-Mail: registrar@ugb.ac.in, Website: www.ugb.ac.in

Affix Passport
size photograph
(Self Attested)

APPLICATION FORM FOR M. Phil. PROGRAMME (2 Years)

SESSION: 2015 2016
To
The Registrar
University of Gour Banga
P.O. Mokdumpur
Dist. Malda
PIN 732 103, W.B.
Sir,
I wish to apply for the M. Phil. Programme in the Department in
terms of your advertisement No.: ../UGB/R-15, Dated-.. The requisite particulars are
furnished below:
1.

Name in full (in block letters): Sri / Smt. /

Km./Ms.

2.

Name of Parents :
a) Fathers name with citizenship:

b) Mothers name with citizenship:

3.

Postal address in full to which

communication should be sent (Please
attach four self addressed unstamped
envelope)
Tel./Cell No.
Dist.
E-mail ID:

4.
5.

Date of Birth (Document must be

enclosed)
a) Whether a citizen of India
b) Religion

PIN

6.

7.

Whether belonging to SC / ST / BC / PWD

SC
(Put tick mark)
(Please attach a certificate in support of
claim)
(i) Marital Status (Put tick mark)
Married

ST

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PWD

BC

Unmarried

(ii) Name of the Spouse

8.

9.

Whether working in any

Institution
on
wholetime/part-time basis (Write
details)
If Yes:
(a) Name
of
the
Institution & Address
with Phone No.
(b) Nature of the post hold
(c) Date of joining

(d) Name & address of

Employer
10. Subject
11. Area of Specialization
12. Language(s) Known
13. University Registration (Please mention No.
the name of the University

Session:

14. Other Relevant Information (if any)

Serial No.: ..
Cost of Form Rs. 500/(Rs. 300/- for SC/ST/BC/PWD)

UNIVERSITY OF GOUR BANGA

P.O. MOKDUMPUR, DIST. MALDA 732 103
WEST BENGAL, INDIA
Phone: (03512 ) 223664 / 223666; Fax: (03512 ) 2235 568

Affix Passport
size photograph
(Self Attested)

E-Mail: registrar@ugb.ac.in, Website: www.ugb.ac.in

Receipt cum Admit Card

Received from Sri / Smt. / Km an application for admission
to the M. Phil. Programme in Arts/Commerce/Science (Please tick) and Department..
Demand Draft No.:; Issuing Bank: ..; Date:
Date: ...

.
Signature of the receiving
assistant with seal

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14.

15.

Whether prosecuting any course of study at

present (If yes, then give details)

Academic records must be specifically mentioned. Self attested copies of mark sheet and certificate
of all examinations should be enclosed.
Marks with
Any other
Exams. passed
Year
University / College / School
percentage / class /
information
Div.

Secondary or
Equivalent
Higher Secondary or
Equivalent (10+2)
Graduation or
Equivalent
Post-Graduation or
Equivalent
Any other qualification
16.

Whether qualified in NET / SET / SLET:

(Certificate to be attached)

17.

Research experience, if any (please attach

separate sheet, if necessary)
Occupation if employed (name & addressed
of the employer) (Pl. attach No Objection
Certificate from the Employer)
Details of Bank Draft, DD No.
Name of the Bank
if applicable

18.

19.

Subject

Year of Passing

Date

Amount

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DECLARATION OF THE CANDIDATE

I certify that the above statements are true to the best of my knowledge. I shall abide by the terms and
conditions as embodied in the University Ordinances relating to M. Phil. Admission to M. Phil. (Session:
2015-2016) Programme is liable to be cancelled if any of the above statement is found to be incorrect.
Date:
Place: ...
....
Full Signature of the Applicant
N.B: All columns shall be filled-up properly. Incomplete form shall not be entertained.

Certification of the Employer

(Applicable in case of in-service candidates)
Certified that Sri/ Smt. has been working on whole time
basis

as

in/of

at

.. since .
The Institution has no objection if he/she carries out 2 Years M. Phil. Programme as regular candidate.

Date:

Signature of the Head of the Institution

with seal

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