CENTRE FOR DISTANCE EDUCATION ACHARYA NAGARJUNA UNIVERSITY::NAGARJUNA NAGAR-522510 PROFORMA APPLICATION FORM FOR STUDY CENTRE
1. Name of the College and Postal Address with Pin-code :
2.
Name of the Educational Society and Registration No. and Date (Enclose copy of Bylaws) Name and Address of the Secretary & Correspondent with Mobile No. (Enclose copy of Resolution)
3.
Mobile No: 4. Name of the Principal with Mobile No. (Enclose copy of the Appointment order) Name of the Co-ordinator with Mobile No. (Copy of the order issued by the Principal) Name of the Office Assistant identified for CDE Programme (Copy of the order issued by the Principal) Name of Affiliating University and Courses sanctioned (enclose copies of affiliation orders) : Mobile No: 5. : Mobile No: : Ph: :
6.
7.
8.
List of Courses for which permission is requested for study centre (Enclose the list)
:: 2 :: 9. For each course/programme, enclose the list of faculty members identified for Teaching weekend classes. You are also requested to submit the Bio-data of each faculty member as given in Annexure-I for considering your request. Without the Bio-data of faculty members your application will be rejected.
10.
Details of Accommodation Available (Enclose Building Photo) Building Area
: : :
No. of Class Rooms : No. of Labs and details : No. of Books in the Library 11. Whether Internet facility is available or not Name of the Website e-mail id 12.
: : :
Information required for fixing of examination centre: a. Particulars of Govt. Colleges located in the same place:
b. Particulars of Aided Colleges located in the same place:
c. Particulars of un-aided Degree Colleges affiliated to local university:
d. Particulars of Junior Colleges located in the same place.
e. Govt. High Schools located in the same place.
Note : If suitable colleges are not available in the same place for fixing of examination centres, the University will allot examination centre in the near by place or district head-quarters.
UNDERTAKING I hereby declare that we shall conduct weekend classes as per the norms laid down by the CDE and shall abide by the rules and regulations of Acharya Nagarjuna University in extending student support services and we agree to the condition that the University reserves the right to withdraw the permission given for offering courses in the event of any deviations or violation of terms and conditions specified in the MOU.
Signature of the Secretary & Correspondent with Seal
ANNEXTURE I BIO-DATA FOR FACULTY MEMBER 1. Name of the Faculty Member and Address with Mobile No. :
Affix latest Photograph
Mobile No. 2. 3. 4. Name of the Father/Husband Date of Birth Educational Qualifications (Enclose Xerox copies of Certificates) : : :
5.
Technical/Professional Qualifications (Enclose Xerox copies of Certificates)
6. 7. 8. 9.
Nature of Appointment Date of Joining Previous Experience Subjects being taught/earlier taught (mention whether UG or PG) (a) Presently Teaching (b) Earlier Taught
: : : : : :
Permanent/Temporary
UNDERTAKING I hereby declare that I am willing to teach the students of CDE as per the syllabus prescribed with focus on examination pattern.
Signature of the Faculty Member
From
Date:
To The Director, Centre for Distance Education, Acharya Nagarjuna University, Nagarjuna Nagar-522510. Sir, I furnish the following information for DEC.
Table A : Study Centre (Give full address) Type of Staff Academic Administrative Technical/ Professional Any other Total Table B: Location of Study Centre Address of Study Centre Name of Coordinator No. of Programmes activated Total No. of Counse llors Full Time Temporary Part Time
Table C: Details No. of Rooms Furniture Equipment
Office
Teleconferencing
Library
Computer Lab
Science Lab
Counseling
Any other : Specify
Thanking You, Yours Sincerely, (PRINCIPAL)
