SAMPURNA INSTITUTE OF ADVANCE STUDIES
(Practice School of Martin Luther Christian University)
184, Old Madras, Indiranagar, Bangalore – 560 038: sam.inst@gmail.com
Appln. No.:
Date of Issue: Affix
current
Date of submission: photograph
Receipt No. & Date:
Please tick ( ) the appropriate box M.Sc Counselling Psychology
Diploma in Counselling Psychology
M.Sc in Pastoral Psychology
1. Name of the Applicant (In Block Letters as in Degree Certificate)
____________________________________________________________________________________________
2. Date of Birth Sex: Male Female
Day Month Year
3. Place of Birth _______________________________________________________________________________
Village City District
4. State__________________________Nationality_____________________Religion________________________
5. Category to which the applicant belongs (SC / ST / BT / BC / Others)_____________________________________
6. Mailing Address______________________________________________________________________________
_____________________________________________________________________________________________
__________________________________Pin__________________Tel______________________________________
7. Father’s Name_____________________________________________________________/_______________
Occupation
8. Mother’s Name_____________________________________________________________/_______________
Occupation
9. Address___________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
10. Annual Income (from all sources)_________________________________________________________________
11. Do you have any disability or physical illness? Yes/No
If yes, give details (this information is to serve you better)________________________________________________
Academic Record:
12. High School Examinations:
SSLC/Equivalent 10th Std Examination
Subject Max Marks Min Marks Total Marks
Obtained
CBSE/MBOSE/Equivalent 12 Std Examination
Subject Max Marks Min Marks Total Marks
Obtained
13. Colleges attended:
Institution Year of Degree Subjects Total Marks
Passing Obtained
Signature of Student:………………….. Signature of parent/guardian:……….............
Date:……………………………. Date:…………………………….
Checklist of Enclosures (Photocopies)
Marks list/transcript of the qualifying high school, P.U.C examinations and degree marks sheets
Candidates applying for PG degree/PG diploma course should provide mark sheets of each semester and a
Transfer certificate from the institution last attended
Birth certificate or an examination certificate showing date of birth
REFERENCE REPORT ON CANDIDATE
Sampurna Institute of Advance Studies (SIAS)
Department of Counselling Psychology
#184, Old Madras Road,
Indiranagar, Bangalore – 560 038
Candidate: Complete the information below before giving this form to a person familiar with your academic and
personal qualifications. Instruct the respondent to mail this report directly to The Principal/The Director
in the above mentioned address.
Name of the Applicant ____________________________ Name of Recommender _______________________________
Birth date ______________________________________ Title ______________________________________________
Telephone ______________________________________ Institution or Company _______________________________
E-mail _________________________________________ _________________________________________________
Programme of Study ______________________________ Department ________________________________________
______________________________________________ Office Address _____________________________________
Application Deadline Date _________________________ _________________________________________________
_________________________________________________
Office Telephone ____________________________________
E-mail ____________________________________________
To be completed by the respondent:
1. I have known him/her as: { } undergraduate student { } graduate student
{ } teaching assistant { } research assistant
{ } other ________________________________
2. I have known him/her for the period of __________________ years and/or ____________ months.
3. I served as his/her: { } research advisor { } department chairperson
{ } teacher in several classes { } teacher in only one class
{ } employer { } major adviser
{ } other ________________________________
4. Please describe this candidate’s previous performance and experiences that relate to the person’s potential
as a psychological Counsellor. Include specific accomplishments and a profile of the person’s strength and
weaknesses in terms of: (a) academic background, (b) professional background, (c) interpersonal style, and
(d) personal characteristics. If desired, you may attach a separate sheet.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
5. Please evaluate the applicant by ticking the appropriate column below: (Assessment on a scale of TEN)
Sl. Exceptional Very Good Good Average Inadequate
No. Opportunity
to observe
(9 – 10) (7. 5 - 8. 9) (6 – 7. 4) (4. 5 – 5. 9) Unassessed
1 Integrity (Overall moral
soundness)
2 Emotional Stability and
maturity
3 Interpersonal Skills
4 Motivation and Diligence
5 Interest & Knowledge
in Psychology
6 Intellectual ability &
critical thinking
7 Communication Skills
(Spoken & Written)
8 Dependability
Note: 1, 2, 3, 7 and 8 are purely personal attributes; 4, 5 and 6 are attributes relating to the subject.
6. Comparing the candidate with graduating psychology seniors, how do you rate the applicant’s OVERALL ACADEMIC
ABILITY?
Below Average Average Above Average Very Good Exceptional
(Lowest 40%) (Middle 20%) (Next 15%) (Next Highest 15%) (Highest 10%)
( ) ( ) ( ) ( ) ( )
7. Please indicate the strength of your recommendation placing an “X” along the scale.
( ) ( ) ( ) ( )
Highly Recommended Recommended Recommended with some Reservations Not Recommended
Thank you for your assistance in evaluating this applicant
Address of Respondent_________________________________________________________________________________
________________________________________________________________________________
Signature__________________________________________________Date______________________________________
