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अभभरर ददरद घघषणद (Declaration By The Applicant) 1. मम एतददरद हवहधवत घघषणद करतद हह/ह करतश हहह कक उपभसकर त दश गभश सभश सहचनदएम सतभ ह।म तथभय कघ हछपदभद भद गलत तरशकक सक पसतसत नहह ककभद गभद ह।ह मनम क हववरहणकद मम पवकश पककभद सममनधश सभश सहचनदएम तरद तथभ पढ हलभक हम तरद मम इनकद अनसपदलन करम गद/करम गश। भकद कक गई पहवहषभय तरद सलम गनक पमदण-पतय मम कघई तरस ट/हवसगम हत पदई जदतश हह तघ मरक द पवकश हनरसत कर कदभद जदए। ऐसश हसरहत मम मम शसलक वदपसश कक हलए ककसश भश पकदर कद ददवद नहह करम गद/करम गश। 2. मम भह घघषणद करतद हह/ह करतश हहह कक ममनक सभश सव-पमदहणत पपत इस आवदक न पत कक सदर सलम गन कर कदभक ह।म 3. हवशवहवददलभ ददरद हनरमत हनभमदवलश कक तहत कस लपहत/कस लसहचव अरवद अनभ अहधकक त वभहक ददरद आवशभकतद पडनक पर हनभमदनसस दर कक गई ककसश भश पकदर कक अनसशदसहनक कदभरवदहश मझस क सवशकदभर हघगश। 4. मम सभश हनभमय/हनणरभय और हवहनभमय कद पदलन करम गद/करम गश। 5. उततरदखणड मसकत हवशवहवददलभ कक समसत परशकदएम कक वल उततरदखणड रदजभ मम हश समपनन हयगश। 1. “I hereby declare that the particulars stated in this application form are true to the best of my knowledge and belief. I have read the prospectus and the admission/eligibility requirements as laid down by the University and I shall abide by them. In the event of suppression or distortion of any fact in my application. My admission will stand cancelled at any point of time. In case my admission is cancelled by the University due to any reason. I shall have no claim for refund of fee paid by me. 2. I hereby declare that I have attached all the required self-attested documents with this form. 3. Further I declare that I shall submit myself to the disciplinary jurisdiction of the Coordinator of the study centre. The Vice Chancellor and Other authorities of the University who may be vested with the power to exercise discipline under the Act. The statutes. The Ordinances framed by the University. In this regard these authorities have the right to take necessary disciplinary action. 4. I agree to abide by the rules and regulations. 5. All examinations of Uttarakhand Open University will be conducted only in Uttarakhand State. सरदन (Place) अभभरर कद नदम (Name of the Applicant) कदनदमक (Date) अभभरर कक हसतदकर (Signature of the Applicant) अधभभन कक नन ददरद सतभदपन एवमम अगसदरण पमदण-पत (Verification and forwarding Certificate by the Study Centre) मम (समनवभक) एतददरद शश/शशमतश/सशस श (अभभरर कद नदम) SHIVAM KULIYAL पतस /पतस श/पतनश RAKESH KULIYAL जघ इस अधभभन कक नन (कघड सहहत) 11125-PANDIT.LALIT MOHAN SHARMA GOVT.P.G.COLLEGE RISHIKESH मम पदठकम BA-17-Bachelor of Arts मम नदमदमककत हए ह,म कद पवकश आवदक न पत अगसदररत करतद/करतश हह।ह मकरक ददरद इस पवकश फदमर कक समसत पहवहषभय तरद सलम गन पमदण -पतय कद मलह पमदण-पतय सक हमलदन कर सतभदहपत कर हलभद गभद ह।ह I (Coordinator, Study Centre) hereby forward this admission form of Mr./Mrs./Ms SHIVAM KULIYAL Son/Daughter/Wife of RAKESH KULIYAL for admission in (Name of Study Programme) BA-17-Bachelor of Arts at (Study Centre name/Code) All the entries in this form and attached testimonials 11125-PANDIT.LALIT MOHAN SHARMA GOVT.P.G.COLLEGE RISHIKESH have been verified by me after comparing the same with the original documents. सरदन (Place) अधभभन कक नन समनवभक कद नदम Name of Coordinator, Study Center कदनदमक (Date) अधभभन कक नन समनवभक कक हसतदकर Sign. Of Coordinator, Study Center मघहर(Seal)

Uttarakhand Open University उतररखडख मकम ववशववदरलय By Debit/Credit/Net-Banking Haldwani,Nainital |हललरनन ,ननननतरल Enrollment No. : 21249333 Reginal Center /Study Center Information/Program Fee Regional Center : 11-Dehradun Study Center : 11125-PANDIT.LALIT MOHAN SHARMA GOVT.P.G.COLLEGE RISHIKESH Program : BA-17-Bachelor of Arts Year/Semester : 1-Year Course Details: FES-(A)10 BAED-101 BAED-102 BAEL-101 BAEL-102 BAPS-101 BAPS-102 Exam City: 20-RishiKesh Study Medium : Hindi Admission Fee : Exam Fee : 1400.00 Additional Fee : 2000.00 Degree Fee : 0 Late Fee : 150.00 0.00 Total Amount : 3,550.00 Name : Father Name : Basic Information Mother Name : Mobile No. : SHIVAM KULIYAL Gender : Male Nationality : RAKESH KULIYAL Date of Birth : 17-Apr-1997 Handicap : RAMA DEVI 918218830475 Name (in hindi) : हशवम कस हलभदल Indian N E-Mail : [email protected] National Id Name : AADHAAR CARD National ID No. : 329508050534 Territory : Rural Marital : Married Cast Category : General Domicile : Uttarakhand Religion : Hindu NAD ID: Economic Class: BPL Livelihood Status: Prison Inmate: Unemployed Eligibility Information Eligibility: N Correspondence Address: Board/University: Year of Passing: 272/2, ASHUTOSH NAGAR, RISHIKESH 272/2, Percentage: Division: 10+2 / Equivalent ASHUTOSH NAGAR, RISHIKE Subject: NATIONAL INSTITUTE OF OPEN SCHOOLING RISHIKESH Application Place : 2021 Uttarakhand 249201 40.67 India THIRD ENGLISH, DATA ENTRY OPERATIONS, PAINTING, COMMERCE/BUSINESS STUDIES, ECONOMICS, ACCOUNTANCY Application Date : 9/28/2021 4:35:43 PM Examination Year University Academic Qualication Per (%) Division Subject HIGH SCHOOL 2014 UTTARAKHAND BOARD 42 THIRD HINDI, ENGLISH, MATHEMATICS, SCIENCE, SOCIAL SCIEN INTERMEDIATE 2021 NATIONAL INSTITUTE OF OPEN 41 THIRD ENGLISH, DATA ENTRY 9/28/2021 SCHOOLING OPERATIONS, PAINTING, COMMERCE 4:41:29PM Page 2 of 2