Application to Under Graduate (UG) Courses

1. Name of the Applicant th(in Block Letters as in 10 grade mark sheet)

2.

Gender: Male FemaleDay Month Year

3. Contact Numbers (Land line with STD Code and Mobile Number)

4. Email ID

5. Place of Birth (City, District, State & Nationality)

6. Passport Number with Validity period (if available)

7. Permanent Address (with PIN code)

8.

Address for Correspondence

9.

Local Guardian’s Address (Address with Phone Number)

10. Father’s Name

Occupation

Telephone / Mobile No.

Email ID

11. Mother’s Name

Photo

A Unit of Sarvodaya Seva Sangha

State the B.A. course applying for:

Preference 1 : ___________________________________

Preference 2 : ___________________________________

Date of Birth Transgender

(with PIN code)

Occupation

Telephone / Mobile No.

Email ID

For office use only

Application No. : Date of Submission:

Eligibility for Karnataka Quota : YES NO

12. Blood Group

13. Religion

14. Caste :

15.

16. Reservation Category (Supporting Documents Required)

General

SC

ST

Cat - I

Cat - II A

III A

Any Other specify ..............................................................

17.

Name of theDegree

1.

Max

Scored

2. Max

Scored

3.

Max

Scored

4. Max

Scored

5.Language 1 Specify

Max

Scored

6. Language 2 Specify

Max

Scored

Mother Tongue

Cat - II B

Academic Background

a. Details of Qualifying Examinations:

Registration No. Name of the College, Board and University. Overall %of Marks

Year & Month of Passing

SSLC/10th/Equivalent

11th/ PUC/Equivalent

12th/ PUC/Equivalent

Others.........

b. Details of Marks:

Optional Subjects Marks Details 11th/ PUC 12th/ PUC TotalAggregatePercentage (%)

Sub - Caste:

III B OBC

19. Application Fee Payment Details

20. Declaration

18. Name, designation and addresses of any two Teachers/Faculty who could be contacted for reference check.

Payment is made by Cash DD Online Transfer

Amount ........................................................Date ...........................Name of the Bank .......................................................

Payment Details (DD no/ Ref No/ UTR No. etc) :.................................................................................................................

For cash payment, Cash Receipt No....................................................................................................................................

1) I hereby declare that information mentioned in the application is true to the best of my knowledge.

2) I agree to abide by the rules and regulations of the Institute in force from time to time if admitted.

3) I am aware that my admission is subject to the approval from Bangalore University.

4) I undertake to intimate the Institute immediately if there is / are any change/s in my permanent

address, correspondence address, Email ID, Phone No. with STD code, Mobile No. etc.,

Date:

Place:

Signature of the Applicant

Signature of Parent / Guardian

(Incomplete Application / Application without mandatory enclosures is liable to be rejected)

2. Name .........................................................................

Address ......................................................................

....................................................................................

....................................................................................

Phone No....................................................................

Email ..........................................................................

1. Name .........................................................................

Address ......................................................................

....................................................................................

....................................................................................

Phone No....................................................................

Email ..........................................................................

Details of the timeline of admission process are available on the IIPR website www.iipr.in

Application forms should be filled up neatly in block letters.

Application forms along with supporting documents may be submitted directly (In -Person) between 10 AM and

5 PM on all working days at the office of admissions or could be sent through registered post, courier service at

the below mentioned address -

Office of Admissions, Indian Institute of Psychology and Research(IIPR),

St. Anthony's Friary, # 85, Hosur Road, Bangalore- 560095.

Following enclosures need to be submitted along with the duly filled in application forms.-

1. Application processing fee details are available on the website link:

http://iipr.in/admission_procedure.html

Fee should be paid by Cash/ Online Transfer / Demand Draft (DD drawn in favour of “IIPR”. Name of

the Applicant and Course Applied for should be written behind the DD).

2. Copy of 10th,11th and 12th Marks Sheets

3. Conduct certificate from the principal of the college / university department last attended / from a

Gazetted office

4. Copy of Transfer Certificate

5. Copy of Migration Certificate for candidates from outside Bangalore University

NOTE : Original Documents pertaining to all the above should be submitted at the time of admission along with

5 passport size photographs.

Guidelines for Submission of Application Forms: