APPLICATION FORM

ASIAN WORKERS DEVELOPMENT INSTITUTE (AWDI)

BASTIA SMRUTI SADAN, SECTOR-6, ROURKELA-769002 1. 2. 3. 4. Application No. : ____________________________

Course Applied For : ____________________________ Hostel Accommodation Required (Y/N) Applicants Name : (In Block Letters)( Sur Name First)

One attested copy of passport size photograph to be pasted here

5. 6.

Sex (Male or Female): Present Address :

8.

Fathers/Husbands name:

9.

Mothers Name:

10. 11. PIN

Ph. No.(code)

Date of Birth: Nationality:

12. Category: (SC/ST/OBC) 7. Permanent Address : . 13. Others Religion Mother Tongue

Place of Birth PIN

Ph. No.(code)

State of Birth Blood Group

14. Email 15. Academic Qualification:

Name of Exam 1)Matriculation or Class X 2)Plus Two (+2) 3)Degree (+3) 4)Post Graduation (or degree if any)

Name of Instn.

Name of Board /University

Year

Division / Class

Stream

16. Students) 17. Details of Training/Work Experience(if any): Nature of Job

University Regd. Number (For Sambalpur University

Name of Organisation

Period From To

18.

Declaration by the Applicant:

I here by agree to abide the rules & regulations of the institution. I also here by declare that all statements made in this application are true, complete & correct to the best of my knowledge & belief. I undertake that , In the event of any information being found false or incorrect at any stage , my candidature is liable to be cancelled. Place Date. SIGNATURE OF THE APPLICANT

DECLARATION (BY FATHER / MOTHER / LEGAL GUARDIAN) I Sri/Smt. father / mother / Legal guardian of ....do here by declare that I have read the rules and regulations of the institute and undertake that my son / daughter / ward shall abide by the same. I further declare that I shall remain responsible for the payment of all fees and charges payable by my son / daughter / ward. I shall also be responsible for good conduct & good behaviour of my son /daughter / ward during the period of his / her studentship in the institute.

I shall not claim or demand under any circumstances refund of the fees paid to the institute in connection with the admission of my son / daughter / ward. Place .. Date

SIGNATURE