Application No. Affix a recent passport size photograph duly attested by a Gazetted Officer VT1: Male I I PIN Mobile No. : ,1141 11gith;EreFdraWrff:, saWaTT:, SHRI JAGANNATH SANSKRIT VISHVAVIDYALAYA SHRI VIHAR, PURI- 752003 ( ODISHA) Fax No. 06752- 251073 E-mail : sanskrit.university @yahoo.com Website : www.s'sv.nic.in SHIKSHA SHASTRI - B.Ed. ENTRANCE TEST - 2016 jr- Trcrfi-air - 0 .? FOR OFFICE USE ONLY Roll No. EXAM CENTRE TITRi31- i.ciAcilTaftzilT, (To be filled in by the applicant ) 1. ill179T14 Name of the Candidate (In Capital Letters) 2. 1H Sex ( Vrt ,16 kqT=Lliut V mark) 1 1f1I Female 3. ff: -11H Father's Name : 4. Trig: -11H Mother's Name : 5. , T1-4-1R-ilg: Date of birth : Day Month Year Age 6. tARroRiv-t, Identification Mark • 7. ,-111 .-11 .d: Address for Communication (In English Capital Letters Only) 8. 3TWEI9VRT (Educational Stream) : (i) LIR 4-LiRch rl (Traditional) 7TRtiaTN1-4/3- FjR) VR-16 (ii) (Modern) f4.7.(#Tzfft) Put mark) Details of Demand Draft Amount : 700/- Name of the Bank : DD No. : Date :
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qtrvq-ru chvilT,31.-1 To7-4 (4-4Rfff 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