Application No.

BILASPUR UNIVERSITY
BILASPUR (C.G.) 495001

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Passport Size

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Photograph
495001

APPLICATION FORM FOR ADMISSION

[ M.Sc. Microbiology & Bio-Informatics (2yrs. PG Course) / B.Com. and M.Com.
(5yrs. Integrated Course) / B.H.M. (Bachelor in Hotel Management & Hospitality)
3 years course / B.Sc. and M.Sc. (Food Processing & Technology / Computer
Science & Application) 5 years Integrated Courses. ]
SESSION : 2015-16

A] Result in the last qualifying Examination

Name of the COST OF APPLICATION

Qualifying Exam Total Marks

SC / ST Other
Marks
Secured Application Fee Nill Rs. 100.00
Prospectus Rs. 250.00 Rs. 250.00
% fo Marks
Total Rs. 250.00 Rs. 350.00

PARTICULARS
Department in which Admission is sought: __________________________________________
Name of the Course Offered : __________________________________________
1. Name (In block Letters) :

2. Date of Birth* :
3. Sex : Male / Female : Male Female
4. Category * : SC ST OBC PWD GEN
SC - Scheduled Caste : ST - Scheduled Tribe : OBC : Other Backward Class : PWD - Person with Disabilities :
GEN - General (Please tick in appropriate boxes & SC, ST, OBC & PWD. Candidates enclosed certificate )

5. Mobile No. & E-mail : ____________________________________________

 6. Mother’s Name : ___________________________________________

7. Father’s / Husband’s Name : _____________________________________________

8. Present Address : _____________________________________________

_____________________________________________

_____________________________________________

8. Permanent Address : _____________________________________________

_____________________________________________

_____________________________________________
9. Nationality : Religion _______________________________________

10. Marital Status : _____________________________________________

11. Proposed Residence in Bilaspur : _____________________________________________

(Own House / Relative’s House/

Rented House / Hostel)

Name of local guardian : _____________________________________________

Address : _____________________________________________

12. Are you employed ? : : Yes No

If yes, please mention and enclose No Objection Certificate from Employer :

a) Employer’s Name and address : ___________________________________

b) Monthly Salary (Attach No Objection : ___________________________________

Certificate from the employer)

13. Have you applied for admission in more : Yes No

than one department

If yes, please state the name of the departments : __________________________________

14. Are you already registered with Bilaspur University : _________________________________

If yes, state your Registration No. with year : __________________________________

(attach a copy)
15. Educational Qualification * :

Board / Council/ % of
Examination Subjects Year Division
University Marks

High School

Intermediate/
Higher Secondary

BA/B.Sc/B.Com.
(Pass / General)

BA/B.Sc/B.Com.
(Major / Hons)

Any other exam.

...........................

*Please enclose attested copies of all documents in support of educational qualification, date of birth and caste etc.

16. In case the result of the qualifying examination of

Bilaspur University is yet to be announced, please
state the examination you appeared with Roll No. : ________________________________________

17. Proficiency in extra-curricular activities, : ________________________________________

if any (Please attach the documents)

18. Scholarship, prize, medal or any other distinction : ________________________________________

won, If any (Please attach documents)

19. Institution where last studied : ________________________________________

20. Were you ever disqualified by this or any other : Yes No

.university from appearing in any examination
If so, give details, : ________________________________________

21. Was any criminal proceeding instituted against : Yes No

you and / or were you ever subjected to any
disciplinary action ?

If so, give details : ________________________________________

22. Reasons for intervening period of gap, if any : ________________________________________

Filled in application form should reach the University by 20th June 2015 either by dropping in box kept in Bilaspur University

or by post addressed to the Registrar, Bilaspur, University, Old High Court Campus, Bilaspur, Dist. Bilaspur (C.G.) 495001.

Note: Attach DD for Rs. 350/- for others/ OBC, and Rs.250/- for SC/ST in case form downloaded from website.
DECLARATION BY THE CANDIDATE
I hereby solemnly affirm that I shall strictly abide by the rules and regulations of the University, as amended
and enforced from time to time and also of the student’s conduct and discipline rules as prescribed by the
University and enforced from time to time, I am neither involved in any criminal case nor is any criminal case
pending against me in any court of law. I have not been debarred / resticated by the institution last attended
/ presently attending. If discovered even after confirmation of my provisional admission that I have made a
false or incorrect statement or concealed any fact or fraudulent means or such means have been used on
my behalf for securing admission, I shall be liable to disciplinary action and cancellation of admission
without prejudice to such action as the University may take against me. I fully agree to follow the Admission
test or Interview / aptitude assessment / Group discussion procedure and shall strictly abide by all the
Instructions of the University authority in the regard.

I, _______________________________________, hereby solemnly declare an oath that the

entries made by me in the above columns are true to the best of my knowledge and belief and if at any time
the entries are found to be incorrect, my admission may be cancelled and disciplinary action may be
initiated against me.
Permanent Address : Village / Town : _________________________ P.S. ___________________________
P.O. : _______________ District ________________ State __________________ Pin ________________
Telephone No. ____________________________________________ (STD Code ______________)
Place : ______________
Date : _______________ Signature of the Candidate

DECLARATION BY GUARDIAN

I, _________________________________________________, have gone through the declaration made

by my son / daughter / ward and agree to abide by all those declarations.

I further declare that I agree to meet all expenses in the University and / or in the hostel of my son /
daughter / ward during the period of his / her course of study. I shall compensate for any loss or damage
caused by my son / daughter / ward to the University’s property.
_____________________________
22. Information for Statistics Purpose : Full signature of Guardian
a) Category (SC/ST/OBC/PWD/General) ________________ Place : _______________
b) Rural / Urban ____________________________________ Date _________________
c) Father’s Annual Income ____________________________
d) Occupation ______________________________________

FOR USE IN THE DEPARTMENT

Certified that the application is in order / not in order. The candidate is recommended / not recommended for
admission.
(Signature)
Chairperson, Departmental Admission Committee

ADMITTED / REGRETTED

(Signature) (Signature)
Registrar Head of the Department

Place : _______________
Date : _______________
 ANNEXURE I
AFFIDAVIT BY THE STUDENT
I (Name of Student) ______________________________________________________________
S/o D/o Mr.. Mrs./Ms of : (Name of Parents/Guardian) _____________________________________

having been admitted BILASPUR UNIVERSITY, BILASPUR (C.G.). have Received a copy of the
UGC Regulations on Curbing the Menace understood the provisions contained in the said
Regulations.

2) I have, in particular, perused clause 3 of the Regulations am aware that constitutes ragging.

3) I have also, in particular clause 7 and clause 9.1 of the Regulations and am fully aware of the
penal and administrative action that is liable to be taken against me in case I am found guilty
of or abetting ragging, actively of passively, or being part of a conspiracy to promote ragging.

4) I here by solemnly aver and undertake that :-

a) My ward will not indulge in ant behavior or act that may be constituted as ragging
under clause 3 of the Regulations.
b) My ward will not participate in or abet or propagate through any act of commission or
omission that may be constituted as ragging under clause 3 of the Regulations.

5) I hereby affirm that, if found guilty of ragging, I am liable for punishment is according to cause
9.1 of the Regulations, without prejudice to any other criminal action that may be taken
against me under any penal law or any law for the time being in force.

6) I hereby declare that my ware has not been expelled or debarred from admission in any
institution in the country on account of being found guilty of, abetting or being part of a
conspiracy to promote ragging: and further affirm that, in case the declaration in found to be
untrue, I am aware that my admission in liable to be cancelled.

Declare this___________ day of ___________ month _________ year

Signature of Deponent
Name : _____________________
Address : ____________________
Telephone/Mob.No:____________
VERIFICATION
Verified that the contents of this affidavit are true to be the best of my knowledge and no part
of affidavit is false and nothing has been concealed or misstated therein.

Verified at _____________ on this this the _____________ of ______________ year.

Signature of Deponent

Solemnly affirmed and signed in my presence on this the ______________of_____________after

reading the constants of this affidavit.
OATH COMMISSIONER
 BILASPUR UNIVERSITY, BILASPUR (C.G.)
ADMIT CARD
ADMISSION TEST : 2015-16
Affix your Recent
Passport Size
Photograph
Application No. :
Name : __________________________________________________
Department : ______________________________________________
Signature of Candidate : ________________________________________
To be filled by the Office

Test Date _____________________ Time : __________________ Roll No. _________________

Venue of Admission test : Bilaspur University, Old High Court Campus, Bilaspur
(C.G.) Personal Interview Date : ____________________________
Date ______________ ________________________
Signature of Registrar/HOD
(Seal)

NOTE :

1. This should be attached with the Application Form at the time of submission.
2. Candidate should bring the admit card at the time of written test and interview.
3. Candidates appearing in test are advised to collect their Admit Card from the departmental Office from
10.00 AM. to 10.45 AM. On 24-6-2015 (No admit card will be dispatched through post.).

BILASPUR UNIVERSITY, BILASPUR (C.G.)

IDENTITY CARD
ACADEMIC SESSION : 2015-16
Name of Student : _________________________________
Father’s Name : _________________________________
Mother’s Name : _________________________________ Affix latest
Date of Birth : _________________________________ Passport Size
Blood Group : _________________________________ photograph
Resi. Address : _________________________________
Mobile No. : _________________________________
Department : _________________________________
Roll No. : _________________________________ Signature
Head of Department
Deptt. of ___________________
Sign. of Student
 ANNEXURE II
AFFIDAVIT BY THE PARENTS/GUARDIAN
I (Name of Parent / Guardian) _____________________________________________________
Father/Mother/Guardian of : (Name of student) ________________________________________

class __________________________________________ having been admitted BILASPUR

UNIVERSITY, BILASPUR (C.G.) have Received a copy of the UGC Regulations on Curbing the
Menace understood the provisions contained in the said Regulations.

2) I have, in particular, perused clause 3 of the Regulations am aware that constitutes ragging.

3) I have also, in particular clause 7 and clause 9.1 of the Regulations and am fully aware of the
penal and administrative action that is liable to be taken against me in case I am found guilty
of or abetting ragging, actively of passively, or being part of a conspiracy to promote ragging.

4) I here by solemnly aver and undertake that :-

a) My ward will not indulge in ant behavior or act that may be constituted as ragging
under clause 3 of the Regulations.
b) My ward will not participate in or abet or propagate through any act of commission or
omission that may be constituted as ragging under clause 3 of the Regulations.

5) I hereby affirm that, if found guilty of ragging, I am liable for punishment according to cause
9.1 of the Regulations, without prejudice to any other criminal action that may be taken
against me under any penal law or any law for the time being in force.

6) I hereby declare that my ware has not been expelled or debarred from admission in any
institution in the country on account of being found guilty of, abetting or being part of a
conspiracy to promote ragging: and further affirm that, in case the declaration in found to be
untrue, I am aware that my admission in liable to be cancelled.

Declare this___________ day of ___________ month _________ year

Signature of Deponent
Name : _____________________
Address : ____________________
Telephone/Mob.No:____________
VERIFICATION
Verified that the contents of this affidavit are true to be the best of my knowledge and no part
of affidavit is false and nothing has been concealed or misstated therein.

Verified at _____________ on this this the _____________ of ______________ year.

Signature of Deponent

Solemnly affirmed and signed in my presence on this the ______________of_____________after

reading the constants of this affidavit.
OATH COMMISSIONER