Application No.

Affix a recent

passport size

photograph duly

attested by a

Gazetted Officer

S:ft `31 4 1 71 1 2R#Tffrarer : SAVTUT : SHRI JAGANNATH SANSKRIT VISHVAVIDYALAYA

SHRI VIHAR, PURI- 752003 ( ODISHA)

Fax No. 06752- 251073

E-mail : sanskrit.university @yahoo.com

Website : www.sjsv.nic.in

SHIKSHA SHASTRI -B.Ed. ENTRANCE TEST -2015

'NAT - o

FOR OFFICE USE ONLY

Roll No. EXAM CENTRE

1:164-717ZP:11)-al/TufrEfIT (To be filled in by the applicant )

1. Trffiviim

mark) l'FkM Female 7=1- : Male

Month I 1 I Year Age

PIN

Mobile No. :

Lilo-L-0Q (Traditional) YIR;4V3TKF4/3T- Fq)

3Treir1A- (Modern) fq- ..(*zff1:0 / 4-L7.( 1=f)

Details of Demand Draft : Amount : 500/- Name of the Bank : DD No. : Date :

Name of the Candidate I I (In Capital Letters)

2. fftT: Sex ( V1";-46 tzliTPut V

3. fcrg: -11 4-t

Father's Name :

4. HIS: RN

Mother's Name :

5. Q-1-4-IR-4:

Date of birth : Day

6. yRrAiRwi, Identification Mark

7. Address for Communication

(In English Capital

Letters Only)

8.3.4%717FITRT (Educational Stream) : (i)

( Vfr4 kTIT:L (ii) Put V mark)

9. .1-ufk---zh-r-zrT ?fLT: 31-F9-T.4-TT

Educational Qualifications

fcRIF..mioqicrkurq: Pi Name of the University/Board

TrapT1-0: Total Marks

72T-0: Marks

Obtained

3td7rdi, Percentage of marks

31 -T: Llia-o-o-H: Courses Studied

k-i ,a-1-11-a?-q-t519, Year of Passing

Trzzrf/ - I (i)Madhyama/

H.S.C .

(ii) dt-RIIQ/

341c1-Y110')/ Intermediate / +2

(iii) 747 B.A.(Sans)/ +3 (Sans)

(iv)31TT-4:/

M.A.(Sans)

(v)3T- Pqj

Any other

10. 3mTuk-oil- (Reservation Category) : SC/ST/PHC Ex-Serviceman/Sports man (National/State Level)

11. 31r4f-{T{Tii,(Residential State) : 12.

. • • • 311Trdli, .

(Studied in SJSV, Puri)

13. 3.1-4#r*T;;RciF.N.iiri

(Studied in Other University)

✓R:1 6 Put ✓ mark)

✓1;4 tzfri) Put ✓ mark)

14. .1(14.11.1 4-11ul4il ul :

(Enclosures) B Provisional Mark List

A (i) Identity Card of SSET (i) Madhyama/HSC (ii) +2

(ii) Admit Card of SSET (iii) Graduation (iii) Self Addressed Envelopes

(one stamped) -2 (iv) Post Graduation

C (i) University Certificate (ii) Reservation Category

(SC/ST/PH/Other)

/ DECLARATION 14P1711 11:4 1-1.,

3TF-ffn - qTrrtile ft-47f 1.14)-1.-11.i *09- zmf-tei- ITO q.-T-T44

41711-11t1IrcReRlItIRA Trapt4R-i ..1 1-1)r-1)-1q-44 I cilFc4c-chic,)

---i-cru-q-Fr H[' all qi1r=c51-i I hereby certify and declare that all statements made and information given by me in

this application are true, complete and correct to the best of my knowledge and belief. In the event of any information or part of it being found false or incorrect before or after the examination/ admission action as deemed fit shall be taken against me by the authority concerned. Date : Place : Signature of the Applicant

■1141 ?11 21147EF9faVaragrr9-4 : SalfaUT : 'at SHRI JAGANNATH SANSKRIT VISHVAVIDYALAYA, SHRIVIHAR, PURI

SHIKSHA SHASTRI -B.Ed. ENTRANCE TEST -2015

-r4-Trzjik-t.7g,,i41 1.4•aair- R0

i1d 4,101+i / Admit Card 1.0.1r-p

Affix a recent

passport size

photograph duly

attested by a

Gazetted Officer

FOR OFFICE USE ONLY

EXAM CENTRE

1. PINIFfirrI/ Full Name :

(In Capital Letters)

2.19: TI/Father's Name :

3. Hs:TIT/Mother's Name

4. ,7I-+-I[-ilk:/Date of birth :

Identification Mark :

Roll No.

4 1 I 21 th:EFAVaragriFir Stfa47 'at SHRI JAGANNATH SANSKRIT VISHVAVIDYALAYA, SHRIVIHAR, PURI

-4/* SHIKSHA SHASTRI -B.Ed ENTRANCE TEST -2015

rf4--Tr7ithq- - R0

4 •r-Iti 71 1-1, / Identity Card

Affix a recent

passport size

photograph duly

attested by a

Gazetted Officer

FOR OFFICE USE ONLY

EXAM CENTRE Roll No.

1.341f471-111:11 Full Name :

(In Capital Letters)

2. fcg: TLI/Father's Name :

3. Hi j: 717/Mother's Name :

4. Q1-41F4-11g:/Date of birth .

5. t-iR=oRiv-i,

Identification Mark :

Date of Examination:

07. 1.1 9-1i, choice of centre :

tit WF-971: Controller of Examinations

IPum 111 CUTTACK BALASORE

Signature of the Applicant

21-06-2015 (10AM to 12 Noon)

E

34*Tgrraro:( Signature of the Applicant

N.B. : Mobile phones, pagers or any other communication devices are not allowed inside the premises where 1.1.10 civnnnirInfinn is r■ nnrliinfor4

6. 4k1TRiTi: / Date of Examination : 21-06-2015 (10AM to 12 Noon)

7. 4-irlt----q-zi91k choice of centre :

TItqFriz: Controller of Examinations

PURI CUTTACK BALASORE 111