Downloaded application should be sent along with a DD for 300/- together with admission fee

ICET/A.U.MBA/MCA ICET/A.U.MBA/MCA
Entrance Test Entrance Test
H.T.No. State Rank

SCHOOL OF DISTANCE EDUCATION Affix Latest

Passport size
ANDHRA UNIVERSITY Photograph duly
Sl.No. VISAKHAPATNAM attested by
Gazetted Officer
APPLICATION FORM FOR ADMISSION INTO
Two Year Executive MBA (Finance / Marketing / HRM)
Three Year MBA (Marketing / Finance / HRM) / M.B.A. Hospital Administration
(SPECIFY THE COURSE)
Note : The applicant should read the Prospectus first and then fill in the form in his/her handwriting in English.
Seeking Admission under :
(Tick () the appropriate box) In-service Category : Fresh Category :

1. Name of the Applicant in full

(in Block Letters) Surname
(As per Degree / Provisional /
Name
Pass Certificate / Original)
[Put Tick Mark ( )]
2. Date of Birth Male Female
1 9 01 02
(enclose attested S.S.C certificate) Day Month Year

3. Name of the Parent / Guardian

4. Address for Communication

(in Block Letters)

Contact Phone/Cell No. PIN

E-mail I.D.: Aadhar No. _______________________

5. Do you claim any of the following reservations ? If so, tick () the appropriate box (es)
Enclose Xerox copies of certificates in support of the claim.
SC ST LBC PH
A B C D VH* HI* OH*
1 2 3 4 5 6 7 8 9

*VH - Visually Handicapped *HI - Hearing Impaired *OH - Orthopaedically Handicapped

6. Details of Qualifying Examination Name of the Examination Year of Passing Name of the University
Passed.
(Enclose Xerox copies)

7. Particulars of the state rank and marks obtained in ICET / Test conducted by SDE. A.U.
MARKS OBTAINED IN
H.T.No. STATE RANK TOTAL
SECTION - A SECTION - B SECTION - C
8. Work Experience : Managerial / Superivisory Name of the Organization Designation Years of Service
(Service Certificate should be signed by the
Employer in the Proforma given)

9. Particulars of the Fee paid : DD No. :

Amount : Place : Date:

DECLARATION OF THE APPLICANT

I hereby declare that the particulars furnished by me are correct to the best of my knowledge and the original
documents will be evidenced with when called for. I am liable for any action to be taken by the University, if the informa-
tion furnished by me is found to be false or incorrect at any stage, I forfeit claim. I have carefully gone through the
Prospectus and I am fully conversant with the eligibility criteria to be satisfied for admission .
Place :
Date : Signature of the Applicant
Check List :
Have you enclosed the following ? Tick () Yes / No :
1. ICET - Rank Card / Entrance Test Rank Card (In case of MBA / MCA course only) Yes / No
2. ICET - Hall-Ticket / Entrance Test Hall-Tickets (In case of MBA / MCA course only) Yes / No
3. Degree Certificate / Provisional Certificate of qualifying examination Yes / No
4. S.S.C or equivalent Certificate (In case of MBA Course only) Yes / No
5. Date of Birth extract Yes / No
6. Caste and Income Certificate in case of SC / ST / BC- C candidates Yes / No
7. Service certificate from Head of the Department / Employer
(in case of in-service candidates for Executive MBA Course only) Yes / No
8. Three Self-Address Slips. Yes / No
SERVICE CERTIFICATE
(In case of Two year Executive MBA Course only)
(To be signed by Head of the Department / Employer)
(The certifying authority is solely responsible for any incorrect information)
This is to certifiy that Sri / Smt./ Kum. ....................................................................................................................
S/o D/o W/o ...........................................................................................................is working in our Office / Institution
as ................................................. which comes under Managerial / Supervisory Cadre from ....................................
till date (Total Service : Years ....................... Months ........................... Days ............................ as on the last date
of submission of application form. His / Her scale of pay is `. ........................................... and his / her gross salary
is `. ................................ PM (Rupees ....................................................................................). His / Her services
are found to be Good / Satisfactory during the above period.
We have no objection for Sri / Smt / Kum. ...............................................................................................................
joining in MBA Programme offered by School of Distance Education, Andhra University through if given admission.
Place : Signature :
Date : Designation with Office Seal :
Phone No.