7. a. Details of Educational Qualification of Head of Organization(From X standard onwards) :

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1 RENEWAL FORM FOR STUDY CENTRE 1. Name of the Institution/ Society Directorate Of Distance Education Rajasthan Vidyapeeth (Deemed) University Pratap Nagar,Udaipur, Rajasthan (for office use only) Name of the Study Centre :_ Code Number of S.C : Place : District : State : Date of Selection : Courses Offered : Space for Photograph Paste one recent passport size photograph prefarably colour of the head of Institution/ Society Please do not Pin or Staple 2. Name of the study centre Incharge 3. Complete Address for Correspondence(Do not repeat name) : State : Pin code : Address Website, if any, then URL Location : URBAN, SEMI-URBAN, RURAL, BACKWARD 4. Telephone Number : STD Code (O) : (R) : (Mobile) : (FAX) : 5. Status of the Institution : - A. Society/ Govt./ University Dept./ Pvt Aided/ Pvt Unaided b. Date of Incorporation/ Commencement of business c. Nature of Business 6. Affiliated to / recognized by university/ any body/ any other body(specify) a. Name of the affiliating body b. Postal address(with district & pin code) c. Phone/ fax/ / Telex(with appropriate codes) 7. a. Details of Educational Qualification of Head of Organization(From X standard onwards) : Name of the Qualifying Examination Year of passing School/College University/Board Percentage

2 b. Work experience of the study centre Incharge Duration Name of the Organisation Designation Responsibilty 8. Your Survey a. Population of city/ town : b. No. of schools and colleges in the area : 9.Faculty (on date of proposal) Sr.no Name Designation Qualification Teaching Date of Total Status experience appointment emoulments full/ part time 10.Laboratory Facilities a. Sr.No. Name of the Laboratory Available area Maximum Batch size b. Major equipment/ machine available (details may be enclosed) 11.Library Facilities( details may be enclosed) No of text/ subject books No of reference books No of encyclopedia No of periodicals No of Journals others

3 12.Infrastructure Facilities (Give a layout of the building, if possible) Particulars Available Area (sq.ft) No. of Rooms Staff room Class room Laboratory Library Reception Rest/ Guest rooms Toilets Any Other 13..Rajasthan Vidyapeeth Courses which shall be conducted at your centre Sr.no Course Title Duration Intake Capacity Batches Full/ Part Course fee per batch per day time Track record of your institute a. Details of courses conducted during previous year (if any) b. Is there any placement assistance in your institute? c. Any other activity carried out? SEAL OF THE INSTITUTE Complete application forms for study centres are to be Submitted to : The Co - Ordinator Regional Service Division Koteshwar Plaza, Nehru Road Mulund (W), Mumbai Maharashtra, India. PH : (022) , , Fax : (022) Website: SIGNATURE HEAD OF THE INSTITUTE Renewal Forms without following annexures will be considered incomplete and will be liable to be rejected : 1. Self Declaration Form on Stamp Paper of Rs.100/- (Annexure I) 2. Declaration for Training Facilities ( Annexure II) 3. Address Declaration on Letterhead of Study Centre (Annexure III )

4 On Stamp Paper of Rs.100/- [Annexure - I] SELF DECLARATION FORM I/We hereby apply for the renewal of my/our Study Centre for session I/We hereby undertake as under : 1. To pay all the outstanding dues. 2. To pay all the fees as per the University Norms. 3. Not to charge any extra fees from the students apart from the fees prescribed in the prospectus. 4. To have the format of my/our advertisement approved by the University before I/We release it to the media. 5. To submit all the forms to the University within the prescribed time limit. 6. To deliver minimum number of counselling hours as per the norms of the University. 7. To individually verify all the documents enclosed with the student forms with the originals. 8. To take full responsibility of all the documents/correspondences signed by my staff on my behalf. 9. To abide by all the rules and regulations of the University as promulgated from time to time. 10. Not to indulge into any sort of criminal/immoral/illegal activity. I/We further acknowledge that if at any point of time the University finds any deficiency in my/our infrastructure or in the support services to the students or if I/we am/are found involved in any sort of unlawful activities, then the university will have the full right to terminate my/our study centre authorization without seeking my/our clarification. For Signature of the Study Centre Head

5 ON THE LETTER HEAD OF THE INCHARGE OF THE TRAINING CENTRE [Annexure - II] To, The Director, Directorate of Distance Education J.R. N. Rajasthan Vidyapeeth University Pratap Nagar, Udaipur (Rajasthan) DECLARATION FOR TRAINING FACILITIES (for the faculty of Engineering Program) Dear Sir/Madam, After careful analysis of University minimum norms, I assure you that we have all facilities as per the requirement of the course _ for the students enrolled in Directorate of Distance Education Janardan Rai Nagar Rajasthan Vidyapeeth University, Udaipur (Raj.). We have no objection for the premises being used by the University Program Study Centre. The University inspection team can visit/inspect the premises at any time. Name of the Training Centre Address Phone Fax Duration of Agreement from to (at least for 3 years) Authorized Signatory of Training Centre Signature of Study Centre Head

6 ON THE LETTER HEAD OF THE STUDY CENTRE [Annexure - III] ADDRESS DECLARATION In Case the Study Centre Premises is owned I, do hereby declare that I own the under mentioned premises which complies with the University requirement and wherein I intend to run the Study Centre of Rajasthan Vidyapeeth University. Address of the Premises I submit to you the following documents as address proof of the proposed Study Centre Premises : 1. Copy of Purchase Agreement. 2. Latest Electricity Bill of the Premises. For Signature of the Study Centre Head In case the Study Centre Premises is rented I, do hereby declare that I have acquired the under mentioned premises on rent/hire/leave& licence which complies with the University requirement and wherein I intend to run the Study Centre of Rajasthan Vidyapeeth University. Address of the Premises I submit to you the following documents as address proof of the proposed Study Centre Premises : 1. Leave & License Agreement OR NOC from owner. 2. Latest Electricity Bill of the Premises. For Signature of the Study Centre Head