Form. No.

General Shivdev Singh Diwan Gurbachan Singh

KHALSA COLLEGE PATIALA

Receipt No..

ADMISSION FORM 2014-15

On-line I.D. ......................

(For Professional and Post Graduate Courses)

Paste
Photograph

Roll No. . (To be given by the office)

1.

Course Applied for ......

2. Name (in block letters) Mr./Ms

3. Father's/Guardian's Name ...........................
4. Mother's Name ..............................
5. Father's/Guardian's Occupation ..........................
6. Office Address .....................................................
7. Annual Income... ................................................................
8. Date of Birth (DD/MM/YY) ............................
9. Religion : Sikh

(if Sikh, whether Amritdhari-Yes/No) Hindu

Muslim

Christian

Any Other

10. Gender : Male

Female

(if female, whether single girl child - Yes/No)

11. Category : General

SC

ST

12. Tick if Applicable : Sports

BC

OBC

Differently Abled

SGPC Member Ward / College Employee's Ward

13. Registration No. (if already given by the university) : .................
14. University Roll No. (Previous, if any). .............
15. College Roll No. (Previous, if any) ...........................
16. Subjects to be Opted :

1st / 3rd / 5th Semester

2nd / 4th / 6th Semester

1.
2.
3.
4.
5.
6.
7.
Add on Subject (If any)

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

17. Permanent Address ......................

Phone/ Mobile No. ...... Email ID (Compulsory) ........
18. Correspondence Address ....................
Phone/ Mobile No. ................................
19. From which area do you belong:

Urban

Rural

20. Mode of Transportation:

Bicycle

Two Wheeler

Neither

21. Speciality in extra curricular activity, if any .........................................................................................................

EDUCATIONAL QUALIFICATION

Name of Examination

University/Board

Year
of
Passing

Roll
No.

Subject(s)
Studied

Marks
Obtained/
Total
Marks

%age of
Total
Marks

Matriculation
10+2
Graduation
Post-Graduation
Any Other Qualification
List of certificates to be attached with the application duly attested by a gazetted officer/university
teacher/ any other officer not below the rank of Assistant Registrar/ Principal of an affiliated college.
1. Matriculation
2. 10+2 or equivalent examination
3. Bachelor's Degree
4. Character certificate from head of the institution last attended
5. Schedule Caste/ Scheduled Tribe/ Backward Class/ Any Other Reservation Certificate (if Applicable)
6. Two Passport size (Unattested) recent photographs with light background
7. Permanent address proof
8. Any other supporting certificate (NSS, NCC, Cultural Activities etc.)

Signature of Applicant

DECLARATION BY THE CANDIDATE

1.
2.
3.
4.

5.
6.
7.
8.
9.

I hereby declare that the entries made and information supplied by me in this form is correct to the best of my
knowledge and no relevant material has been concealed therein.
The certificates attached along with this form are true copies of the originals.
My admission is provisional subject to registration with Punjabi University, Patiala.
In order to be eligible for the Semester Examination, I fully understand that I shall have to attend at least 75% of
the lectures delivered in each subject, both Theory and Practical in the class up to the day when the class is
dispersed and will obtain minimum percentage of marks as determined by the University in the House Examination.
I undertake to abide by rules and regulations of the college framed from time to time.
I have not been disqualified by any University/ Educational Institution for undergoing said course.
I have not been involved/convicted in any criminal case anywhere in the country or outside.
I will not participate in any strike / dharna in the college and will maintain the discipline of the institution.
I will follow the given dress code and will always carry the Identity Card with me.

Place .

Signature of Applicant

UNDERTAKING BY PARENT/GUARDIAN
I, ensure the obedience/implementation of the above declaration by my ward. I will also ensure the timely deposit of fee and
funds of the college. I also own the responsibility that my ward will follow the discipline of the college and will attend the classes
regularly. I will contact college officials from time to time in order to check the progress of my ward.

Signature of Parent/Guardian
with Phone Number

Checked By
(Name & Signature)

Signature of Convenor
(Admission Committee)

Principal