INDIRA GANDHI NATIONAL OPEN UNIVERSITY

MAIDAN GARHI, NEW DELHI-110 068 APPLICATION FORM FOR B.ED. ENTRANCE TEST CUM ADMISSION-2012
(To be submitted only at concerned regional centre)
FORM NO.

INSTRUCTIONS
1. 2. 3. 4. 5.
0

Please read the instructions in the information brochure before filling up the form. Use BLACK BALL POINT PEN in boxes using English capital letters or English numerals. Do not make any stray marks on this sheet. Do not staple, pin, wrinkle scribble, tear or wet this sheet. Write in CAPITAL LETTERS only within the box without touching the lines as shown in the Sample below.
1 2 3 4 5 6 7 8 9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

CONTROL NUMBER :

1. Regional Centre Code

2. Programme Centre Code

3. State Code

4. Category

A1 - GEN C3 - ST B2 - SC D4 - OBC (Write the relevant (In case of OBC student, Please also indicate code either) code in the box) D4A or D4B i ) Cremy Layer - D4A ii ) Non-Creamy Layer - D4B

5. Nationality
(Write the relevant code in the box) A1 - Indian B2 - Others

6. Sex
(Write the relevant code in the box) A1 - Male B2 - Female

7. Marital Status
(Write the relevant code in the box) A1 - Married B2 - Unmarried

8. Whether Minority :
(Write the relevant code in the box)

9. Religion (Write the relevant code in the box)

A1 - Hindu D4 - Sikh G7 - Paris B2 - Muslim E5 - Jain H8 - Jews C3 - Christian F6 - Buddhist I9 - Others

10. Date of Birth Date Month

Year

A1 - Yes B2 - No 11. Social Status (Write the relevant code in the box) A1 - Ex-service man B2 - War widow C3 - Not applicable

12. Whether Kashmiri Migrant ?

(Write the relevant code in the box) A1 - Yes B2 - No

13.

Territory
A1 - URBAN B2 - RURAL C3 - TRIBAL

14. Employment Status

C3 - Employed A1 - Unemployed B2 - IGNOU Regular Employee D4 - KVS Employee

15.a. Whether a person with disability (write the relevant code) A1 - Yes B2 - No

15.b. If a person with disability (nature of disability) (Write the relevant code in box) A1 - Hearing Impairment B2 - Locomotor Impairment C3 - Visual Impairment D4 - Reading Disability E5 - Any other, Please specify

16.a. Are your registered with (Ignou)

(Write the relevant code in the box) A1 - Yes B2 - No

16.b. If yes write the Enrol. No. & Program Code in the boxes below : Enrolment No. Programme Code

17. Medium Code

A1 - English B2 - Hindi If other please specity :

(Write the relevant code in the box)

18. Details of Scholarship being received if any :*b) Dept. Offering (Write (a) Annual Scholarship Amount
the relevant code in the box) Scholarship A1 - Govt Deptt. B2 - Other

(c) Family income (yearly)

Fold from here 19. Name of the Candidate (Leave one box empty between First Name, Middle Name & Surname

(d) Please indicate in (e) In case of Jail Inmates case of below poverty (Write the relevant code in the box) line A1 - Yes A1 - Yes B2 - No B2 - No

20. Name of Father/Mother/Husband (Strike out whichever not applicable)

21. Educational Qualifications : (Graduation and onwards) (c) Year of Passing (a) Qualification (b) Main Subjects

(d) Division

(e) % of marks

(f) Board Code

Code

(last 2 digit only)

(01, 02, 03 or 04) for pass

(Do not use decimal)

(Whether required)

22. Optional Subject (Code) (i) Group B - Content-based methodology Courses (Two)

(II) Group C - Special Course (One)

23. Write name & Complete Mailing Address (in BLACK BALL Point Pen only)

24. For Office Use Exam Centre Code :

26. Photograph

Name : Exam Centre Code : Address : Affix your latest passport size photograph (4cm x 5 cm) duly attested by Gazetted Officer

25. Candidates Signature

PIN CODE :

27. Address for Correspondence (Do not give Post Box No. Leave a box between each unit of address like House No., Street Name, P.O., etc.) Do not repeat Students Name/Fathers Name

City

District

State

Pin Code

28. Telephone Number (if any) with STD Code/Mobile No. STD Code Telephone No.

29.

Mobile No. (if any) with STD Code STD Code Telephone No.

30. E-mail address/ID (if any)

31. Teaching Experience (Please give details chronologically including present employement) Name of the school Nature of post (temporary/ Permanent) with years with address Type of School (Govt./Govt Registration Post held (PGT/TGT/Primary aided/unaided) No.of the Teacher/Asst. Teacher) School No. of years

Total Full Time Teaching

Experience

Years

Months

Employment Certificate
(To be provided by the Principal/Headmaster/Headmistress) This is to certify that Mr./Ms............................................................................................... has been teaching in this school since ................................................................... as Post Graduate/Graduate/Primary/Assistant Teacher teaching at Sr. Sec. / Secondary/ Prmary level and He/She is a full time temporary/permanent teacher of this school. He/She has ................................................... years of teaching experience. This school is Govt./Govt. aided/unaided and is duly recognised by the central or a state government or a union territory. Signature of Principal/Headmaster/Headmistress Name : ................................................................ Designation : ...................................................... Name of School : ................................................ Registration number of School: ......................... Place : ........................... Address of School : ............................................ Date : ............................. Seal/Stamp .........................................................

DECLARATION BY THE APPLICANT

I hereby declare that I have read and understood the conditions of eligibility for the B.Ed. programme for which I seek admission. I fulfil the minimum eligibility criteria and I have provided necessary information in this regard in the application form. I shall provide proof of my eligibility along with the original certificates in the event of qualifying for admission after Entrance Test. I have carefully studied the rules of the University as printed in the prospectus and I accept them and shall not raise any dispute in future over the same rules. In the event of any information being found incorrect or misleading, my candidature shall be liable to cancellation by the University at any time and I shall not be entitled to refund of any fee paid by me to the University. Date : ................................. (Signature of the Applicant)

INSTRUCTIONS FOR CANDIDATES

1. 2. 3. 4. 5. 6. Please send your Application form by Regd. Post/Speed Post to the Regional Centre under whose jurisdiction area you are Teaching. Details of Regional Centre are given in Annexure-I in the student handbook and prospectus. Application form submitted to any other Regional Centre will not be entertained. The last date for the receipt of filled in application form at the concerned Regional Centre is 15th July, 2011. Application received after this date will not be accepted. Please retain the photocopy of the form for future reference. No documents are to be attached with this application form. Application form received without employment certificate will be rejected.