FOR GENERAL / OBC CATEGORY

INDIAN MARITIME UNIVERSITY

(A Central University)
MUMBAI CAMPUS,
KARAVE, NERUL, NAVI MUMBAI – 400 706.

APPLICATION FORM FOR ADMISSION

Session – 2011
PLEASE READ INSTRUCTIONS FOR FILLING UP APPLICATION FORM CAREFULLY
INCOMPLETE APPLICATION IS LIABLE TO BE REJECTED
(ALL ENTRIES TO BE FILLED IN CAPITAL LETTERS)

1. FORM No.
(will be allotted by IMU)
Please paste
2. REGISTRATION No.
(do not pin)
(will be allotted by IMU)
PHOTOGRAPH
of Size
3. IIT-JEE 2011 APPLICATION No.
4.5 cm x 3.5 cm.
(to be filled up by the candidate)

4. IIT-JEE 2011 REGISTRATION No.

(to be filled up by the candidate)

5. Name (in full)………………………………………………………….……...…………………………………

………………………………………………………………………………………………………………….
(as given in the records of Secondary Education Board/University)

6. Nationality : 7. Sex: 8. Category : GENERAL / OBC

9. (a) Name of Parent Mr./Mrs…………………….……………………………………………………………..

(b) Occupation of Parent: Service / Business…………………………………………………………………
(c) Name of Office/Business where working:… ……………………………………………………………....
(d) Designation of Parent:……….……………………………………………………………………………..
(e) Monthly Total Income/Salary of Parent:………..…………………………………………………………..
10. Name of Guardian (if parents are not alive)…………………………………….……………………………...
Relationship with Guardian..…………………………………………………………………………………...
11. Permanent Address of Parent/ Guardian………………………………………………………………………..
.……………………………….…………….……………….…………………………………………………..
……..…….…………………….………………………………….PIN……………….……………….
Telephone Number (with STD Code)……….………………………Mobile No.……………………….
12. Address for Correspondence………………………………………………………….……..……….................
……………………….….………………………………………………………………………………………
….……………………………………………………………………… PIN………………….……................
Telephone Number (with STD Code)………………………………….Mobile No. ………………………....
13. E-mail Address (if any) ……………………………………………………………………………………
14. Date of Birth (in words) ….……………….………………….…………………..…………………
Date Month Year
(in figures)

Age as on 1st October 2011 …..………Years ………….. Months…….…….Days

15. Details of Examinations Passed
Marks
Month & Year Aggregate
Name of Name of Secured/
Level in which passed/ Subjects Percentage
Examination School/College Maximum
appeared/appearing (%)
Marks

10th Std.

10 + 2

After 10+2
(if any)

16. Indicate
T.S.CHANAKYA M.E.R.I., KOLKATA M.E.R.I., MUMBAI NMA, IMU,
preference for
MUMBAI CAMPUS KOLKATA CAMPUS MUMBAI CAMPUS CHENNAI CAMPUS VISAKHAPATNAM
the Institute you
CAMPUS
wish to join:

17. Eye Sight - Power LEFT EYE RIGHT EYE

18. Declaration by the Applicant

I…………………………………….hereby declare that all the particulars stated in this application
and enclosures are true to the best of my knowledge and belief. I have read the Information Brochure
and I Shall abide by the terms and conditions therein. In the event of suppression or distortion of any
fact like category, educational qualifications, nationality etc., made in my application form, I
understand that I will be denied admission and if already admitted, my admission/degree acquired is
liable for cancellation. I also understand that the decision of the Admission Board regarding my
admission to B.Sc. (Nautical Science) / B.Sc. (Maritime Science) / B. Tech. (Marine Engineering) / B. Tech.
(Naval Architecture & Ocean Engineering) Degree Course is final and I shall abide by the decision.
Further, if admitted I promise to abide by the rules and norms of discipline of the Institute I join.

(Signature of Applicant)
Place ……………………
Date……………………..
19. Declaration by Parent/Guardian
I………………………………………hereby certify that the particulars stated in this application
by my son/daughter/ward Mr./Ms……………………………..…….………….are true to the best of my
(Name of the applicant)
knowledge and belief and in the event of any false information, the final decision of the authorities
concerned shall be binding on my son/daughter/ward.

Date……………………….. (Signature of Parent/Guardian)

Note : Crossed Demand Draft of Rs. 800/- should be drawn in favour of Indian Maritime University,
Mumbai Campus and be enclosed along with this application form, failing which application
will be rejected.
DD No DD Date DD Amt. Name of the Bank