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UGC - NATIONAL ELIGIBILITY TEST JUNE, 2012 Print Copy of Application Form
(TO BE SUBMITTED TO THE TEST CENTRE IN DUPLICATE)

To be Filled by the Test Centre only

Roll No. 36060525

The particulars furnished by the candidate have been checked and verified

University of Madras, Chennai-600 005(36) UNIVERSITY TEST CENTRE

__________________________ CO-ORDINATOR (Signature)

Subject Code Centre Code

06 36 __________________________ OFFICE SEAL

NET Examination Detail

1. 2. (i) 2. (ii) 3. 4. Applied for Post Graduation Examination Subject of Post-Graduation Subject opted for NET Centre of Examination : : : : : Lectureship only Passed History History University of Madras, Chennai-600 005(36)

Affix recent Passport size Photograph signed by the candidate and duly attested by the Head of the Deptt./Institution or Class I Gazetted Officer (DO NOT USE STAPLER OR PIN)

Personal Information
5. Name (as per Hr. Sec. Matriculation : Mr. GNANAASHOKEDJSON Certificate Date of Birth (as recorded in matriculation or : 23-05-1968 equivalent certificate) Sex : MALE Whether relaxation in age is sought 8. 9. Category : ST Visually Handicapped (V/H) / Physically : Not Applicable Handicapped (PH) 10. (i) 10. (ii) 11. Father's Name Mother's Name Address for Communication : Shri G.SOOSAIRATHNAM : Smt. S.LOURDASMARYRATHNAM : PLOTNO62SRIVARTHAMANNAGAR,ANNAIANJUGAM,MANNIVAKKAM,URRABAKKAM, CHENNAI, TAMILNADU, INDIA, 603211
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7.

No

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12.

Permanent : PLOTNOAddress 62SRIVARTHAMANNAGAR,ANNAIANJUGAM,MANNIVAKKAM,URRABAKKAM, CHENNAI, TAMILNADU, INDIA, 603211

Detail of Educational Qualification

13. (a) 13. (b) 13. (c) 13. (d) 13. (e) 13. (f) Examination Appearing/Passed : MA Name of the University : Year of Passing : Subject Offered : Specialization ( if any ) : Marks/Grade : Marks Mark Obtained : 414 Total Marks : 800 % of marks obtained : 51.75% Annamalai University 2003 history

Passed M. Phil: Yes Name of the University : Vinayaka Missions Research

Passed Ph. D.: No

Foundation
Year of Passing: 2009 Subject Offered: history Specialization ( if any ):

14.

Detail of Fee Deposited

Name of the Bank Name of the Branch Branch Code Journal No. Deposit Date Amount : : : : : : : STATE BANK OF INDIA Westsaidapet 11720 020709716 27-04-2012 Rs. 225 Tamil Nadu(23)

15.

The State/UT which you belong

Place: Date: Email:

Chennai 03-05-2012 ashokedison.g.s@gmail.com

Phone No. (with STD Code) Mobile No.: 9444454222

Declaration
i) I, GNANAASHOKEDJSON, hereby declare that all statement made in this application are true, complete and correct to the best of my knowledge and belief and in the event of any information being found false or incorrect or any ineligibility being detected before or after the test, my candidature is liable to be cancelled and legal action may be initiated against me. ii) I fulfill all conditions of eligibility regarding age limit, educational qualification etc. prescribed for the test. iii) I have gone through the conditions attached to NET and shall abide by the same. iv) I have deposited the required fee. v) I have noted that if my application is found incomplete/defective, the same is liable to be rejected summarily and no correspondence will be entertained in this regard. www.ugcnetonline.in/viewForm.php?id=36060525&jno=020709716

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vi) I have read and agree with the Notification for the UGC NET including instructions, enclosures, check list and other relevant information.

Signature of Candidate________________

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