APPLICATION FOR ADMISSION TO_________________ PROGRAMMES 2010-2011

Enrolment No. (For office use only)

Affix a passport size photograph duly signed by the candidate at the top and attested by a Gazetted Off icer at the bottom

Manasagangotri, Mysore – 570 006, Karnataka, India

&

SANDIP FOUNDATION, MUMBAI - 400 080

KARNATAKA STATE OPEN UNIVERSITY

1. Name of the Applicant as in the Marks Card of Standard X exam :

2. Father’s / Husband’s Name :

3. Mother’s Name :

4. Date of Birth : 5. Sex : 6. Nationality :

Date

M FMonth Year

7. Mother tongue :

8. Complete Address of Student for Correspondence (Do not repeat name) :

9. STD Code : Phone : E-mail :

10.Study Centre Code : Name of the Centre : City or Town :

11.Course Applied For : Stream : Semester :

12.DD Number : DD Date :

Date Month Year

13.Name of the Bank :

City : State : Pin Code :

( )

Amount :

Examination Passed Month & Yearof Passing

Subject Percentageof Marks

Name of theBoard/University

14.Educational Qualification (10th Onwards) :

¨ Check List :

Date of Birth Certificate/Proof X th Marksheet X th Passing Certificate

XII th Marksheet (PCM) XII th Passing Certificate

Diploma Final sem./year Marksheet Diploma Passing /Provisional Certtificate.

This is to declare that, I___________________________________________________________________Son/Daughter of

______________________have taken admission in ____________________ Course in (Winter / Summer) semester. 200___ in

_____________________ Stream under Directorate of Distance Education. Karnataka State Open University, Mysore. and I

assure that all the attested document enclosed related to my qualification regarding the admission are correct and authentic.

In the event of suppression or distortion of any fact like educational qualification, nationality and study period etc. Made in

my application form, I understand that my admission is liable to be cancelled.

I acknowledge the receipt of prospectus of Karnataka State Open University, and certify that I have read and understand all

the provisions indicated therein.

I certify that I am qualified for the course as indicated in the prospectus and will produce the original certificate when asked

for.

I understand that university has the right to add/delete/change the syllabi, course structure, rules and regulations as and

when required, as per change in environment.

I understand that the FEES once paid will NOT be refunded.

I am eligible for the examination as per the rules and regulations of the university. I shall be responsible for the consequences

if the information filled by me is found incorrect. If I am found ineligible for admission to a class, at any stage, my application

will be rejected even if my result has been finally declared.

UNDERTAKING BY THE STUDENTS

To,

The Dean Academics

Karnataka State Open University,

Mysore, Karnataka.

Sir/Madam,

Undertaking by the Study Centres

This is to certify that Mr./Ms./Mrs._____________________________________________________________________________________

Son / Daughter / Wife _______________________________________________ is a student registered from our Study Centre. The photo pasted on this form depicts his/her current appearance correctly. I have personally checked all the documents enclosed herewith the originals. I attest that all the entries are correct. I, as well as the candidate, Know that if his/her result finally not declared due to ineligibility. I and the students shall bear full responsibility for rejection and not the University.

Place : _______________

Date : _______________

Signature of the Centre Head :

Study Centre Code : ________________

Seal

Place : _______________

Date : _______________

Signature of the Candidate

Enrolment No. ____________________________

Photo

Any Other Supporting Document

I.T.I./NCVT./MCVC Marksheet & Certificate

KARNATAKA STATE OPEN UNIVERSTIY

MANASAGANGOTRI, MYSORE - 570 006 & SANDIP FOUNDATION, MUMBAI - 400080

Appl No.

APPLICATION FOR ADMISSION TO ------------------------------ PROGRAMMES 2010-2011

STUDENT’S PERSONAL INFORMATION ( PLEASE FILL IN BLOCK LETTERS)

1.NAME 2. ROLL NO:

3. DATE OF BIRTH 4. KARNATAKA OTHER STATE 5. COURSE OPTED

( As Per Marks Card )

6. PLACE OF BIRTH & DISTRICT

7. MOTHER TONGUE 8.SEX : MALE FEMALE

9. NAME OF FATHER/ GUARDIAN/HUSBAND 10.NAME OF MOTHER

11. NATIONALITY Indian Non Indian

12. POSTAL ADDRESS OF APPLICANT

Pin Code

13. CONTACT NUMBERS

(1) OFFICE (2) RESIDENCE

(3) MOBILE (4) E-MAIL

with STD code

14. CATEGORY Tick ( ) box SC ST I IIA IIB IIIA IIIB GM 15. ANNUAL INCOME

16. WHETHER Tick ( ) box PHY. CHALLENGED EX. SERVICEMANDEFENCE 17. Admission Cycles 1st Cycle January 2nd Cycle July

18.Qualifying Examinations Passed

Examination passed Board/University Reg.No.& Year of Passing MarksObtained % of Marks Class

Obtained

Full timeservice

Part timeservice

Business Agriculture Unemployed House Wife Retired Other

20.NAME OF THE STUDY CENTRE & CODE

21. FEE PAYMENT DETAILS ( KSOU SHARES)

FEE PAID D.D NO.

DATE

BRANCH OF REMITTANCE

NAME OF THE BANK

22. FEE PAYMENT DETAILS ( PARTNERSHIP INSTITUTION SHARES)

NAME OF THE BANK

SL. NO TYPE OF FEE AMOUNT ( Rs.)

PROGRAMME / TUTION FEE & LAB FEE

TOTAL

FEE PAID D.D NO.

DATE

BRANCH OF REMITTANCE

Place:Date :

SPECIMEN SIGNATURE

Signature of the Applicant

(I) Qualifying or equivalent Marks Cards ( Attested)(ii) Transfer Certificate ( Original )(iii) Caste Certificate ( for Karnataka Students ) ( Attested)(iv) Four Stamp Size Photographs ( Write your Name & Application no. on back side of the photo )

ENCLOSURES

19.APPLICANTS PROFESSION ( )

SL. NO TYPE OF FEEAMOUNT ( Rs.)

1. PROGRAMME / TUTION FEE

REGISTRAION FEE

ELIGIBILITY / NRI / FOREIGN STUDENTS(ELIGIBILITY FEE FOR NON-KARNATKA ONLY )

2.

3.

4.

5.

TOTAL

PENAL FEE

EXAMINATION FEES

Papers offered

Stamp Size Photo

1.

2.

3.

4.

5.

6.

7.

1. 2.

KARNATAKA STATE OPEN UNIVERSITYManasagangotri, Mysore – 570 006, Karnataka, India

SANDIP FOUNDATION2nd Floor, Koteshwar Plaza, J.N. Road, Mulund, Mumbai – 80, Maharashtra, India

&

IDENTITY CARD

Name of the Student :

Roll No. :

Year of Admission : Cycle :

Name of the Study Centre & Code :

Address :

January July

Photograph

Name of Programme :

Name of the Course & Semester :

Signature & Seal of the Institution Signature of the Student

Deputy Registrar (Admission)

Identity Card is not Transferable

It is a valid only when the Identity Card of the Student is duly attested by the Deputy Registrar (Admission), KSOU, Mansagangotri, Mysore - 06.

UNDERTAKING FORM(BY THE STUDENT)

Photo

To,The Dean AcademicsKarnataka State Open UniversityManasagangotri, MysoreKarnataka - 06

Sir/Madam,

This is to declare that, I _____________________________________________________________________________ Son/Daughter of ________________________________________ have taken admission in ____________ programme in (January/ July) 20 _____ in __________________ Stream under Karnataka State Open University. And I assure that all the documents enclosed related to my qualification regarding the admission are genuine and authentic.

I say and submit that I am under going ________________________ programme of Karnataka State Open University, Mysore to gain and enhance my knowledge and Academic value and I may not get advantage in teachings job.

I say and submit that to gain and enhance my knowledge and Academic value I want to Join ___________________________ programme / academic course of Karnataka State Open University, Mysore and further advancement of my professional career.

In the event of suppression or distortion of any fact like educational qualification, documents related to nationality and study period etc. made in my application form, I understand that my admission is liable to be cancelled.

I am eligible for the examination as per the rules and regulations of the university. I shall be responsible for the consequences if the information filled by me is found incorrect. If I am found ineligible for admission to a class, at any stage my application will be rejected even if my result has been finally declared and consequently such result also would be void.

I further say and submit that even if I do not get any advantage of said course after its completion, I hereby undertake not to hold the above University, its Institute or any other person responsible in any manner for getting no benefit of said course. I say and declare that above course advanced by said University is only for enhancement of my knowledge and nothing more and with that clear understanding I joined the said course at my own risk and cost. I further say that I have gone through the prospectus of said University and I am fully satisfied with contents of the same.

I also undertake not to claim any damage for the same.

Whatever is stated hereinabove is true and correct to my own knowledge and belief.

Place :

Date :

Enrollment No./Roll No.

Signature of the Candidate

UNDERTAKING BY THE STUDY CENTRE

This is to certify that Mr./Ms./Mrs _______

Son/ Daughter / Wife________________________________________ is a student registered from our Study Centre. The photo

pasted on this form depicts his /her current appearance correctly. I have personally checked all the documents enclosed

herewith. I attest that all the entries are correct. I, as well as the candidate, Know that if his/her result is finally not

declared due to ineligibility, I and the students shall bear fully responsible for rejection and not the University.

________________________________________________________________________

Seal & Signature Of The Centre InchargeCentre Code :

Document to be enclosed :

The applicant is required to enclose the attested photocopy of the following supporting documents :

1. Birth Certificate/Any Certificate showing date of birth.2. Basic Qualification Certificates (Xth onwards)3. Passing/Provisional Certificates.

Note :

(I) All documents in support of qualification must be duly attested by Notary only.(II) All attested photocopiers have to be verified by the Director/Co-coordinator, Study Centre at the time of filling this under-taking form.

CHANGE OF EXAM CENTRE FORM FOR SESSION YEAR EXAMINATION ______ _____

KARNATAKA STATE OPEN UNIVERSITY

&Academic Collaborator

SCOPE, Bangalore - 24

Manasagangotri, Mysore – 570 006, Karnataka, India

1. Enrollment No. / Roll No. of the Student 2. Study Centre Code

3. Full Name of the Student (As registered with the University)

4. Father’s Name (As registered with the University)

5. Complete address for Correspondence (Do not repeat name)

Telephone No. with STD Code Pincode

6. Course : Stream : Semester :

7. Name of Examination Centre, where the Student requests to be transferred. (Transferee Exam Centre)

8. Bank draft number with details

Bank Name : Amount in Rs. :

DD Number : DD Date :

10. Certificate by Center Co-ordinator :

Certified that the Enrollment number/Roll number, Name, Examination Particulars have been verifiedand found correct as per the record.

Signature & Seal of the Centre Head of theStudy Centre

9. Specimen Signature of the Candidate

Date :

¨

Rs. 1000/- Demand Draft should be made in favour of ‘THE FINANCE OFFICER, KSOU , payable at MYSORE,

as change of exam centre fees.

NOTE :

’