£ÀªÀÄÆ£ÉUÀ¼ÀÄ

Formats
 Cfð ¸ÀASÉå/Application No:
PÀ£ÁðlPÀ ¸ÀPÁðgÀ/ Government of Karnataka
¥ÀzÀ« ¥ÀƪÀð ²PÀët E¯ÁSÉ / Department of Pre-University Education
¥ÀæxÀªÀÄ/¢éwÃAiÀÄ ¦AiÀÄĹ zÁR¯Áw Cfð/ I /IIPUC Admission Application Form 2020-21
PÀbÉÃj G¥ÀAiÉÆÃUÀPÁÌV ªÀiÁvÀæ / For Office use only EwÛÃa£À ¨sÁªÀ avÀæªÀ£ÀÄß
CAn¹
1. zÁR¯Áw ¸ÀASÉå/ Admission No
Affix recent
2. SATS NO.:
3. ¨sÁµÉU¼ À ÀÄ –ªÀ-¸ÀAAiÉÆÃd£É/Languages –cum- combination: pass port size
4. ªÀiÁzsÀåªÀÄ/ Medium: photograph

5. «¨sÁUÀ/ Section:
6. «ÄøÀ¯Áw ªÀUÀð/ Reservation category:

1. «zÁåyðAiÀÄ ¥ÀÆtð ºÉ¸ÀgÀÄ

Name of the Student in English
as entered in SSLC marks card
(CAPITAL LETTERS ONLY)

2. a) ºÀÄnÖzÀ ¢£ÁAPÀ/ ¢£À/DAY: wAUÀ¼ÀÄ/MONTH: ªÀµÀð/YEAR:

DATE OF BIRTH

b) °AUÀ/Gender :

c) ºÀÄnÖzÀ ¸ÀܼÀ: gÁdå f¯Éè vÁ®ÆèPÄÀ

Place of birth State District Taluk

3.
a) gÁ¶ÖçÃAiÀivÉ/Nationality: b) zsÀªÀÄð/Religion: c) eÁw/Caste: d) G¥ÀeÁw /Subcaste:

4. «zÁåyðAiÀÄ «¼Á¸À SÁAiÀÄA «¼Á¸À/Permanent Address ¸ÀܽAiÀÄ «¼Á¸À/Local Address

Student’s Address

5. a) ªÉƨÉÊ¯ï £ÀA./Mobile No:

b) DzsÁgï ¸ÀASÉå/Aadhar No: (EzÀÝ°è/If avialable)
c) «ÄAZÀAZÉAiÀÄ «¼Á¸À/E-mail Id:

6. a) «zÁåyðAiÀÄ vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ/Name of Father:

b) «zÁåyðAiÀÄ vÁ¬ÄAiÀÄ ºÉ¸ÀgÀÄ/Name of the Mother:

7. ¥ÉÆõÀPÀgÀ/¥Á®PÀgÀ ºÉ¸ÀgÀÄ/«¼Á¸À:
Name/Address of the Parents/Gaurdian:

8. ¥ÉÆõÀPg
À À/¥Á®PÀgÀ ªÁ¶ðPÀ DzÁAiÀÄ: DzÁAiÀÄ ¥ÀæªÀiÁt¥ÀvÀæ ®UÀwÛ¹zÉAiÀiÁ? ºËzÀÄ/E®è
Parent’s /Guardian Annual Income: Is Income Certificate enclosed? Yes/ No
 9. F »AzÉ ªÁå¸ÀAUÀ ªÀiÁrzÀ ±Á¯Á/PÁ¯ÉÃf£À ºÉ¸ÀgÀÄ ªÀÄvÀÄÛ «¼Á¸À:
Name and address of the School /College last studied:

«zÁåyðAiÀÄ SATS NO.:

10. vÀÉÃUÉðqÉAiÀiÁzÀ J¸ïJ¸ïJ¯ï¹/vÀvÀìªÀiÁ£À ¥ÀjÃPÁë «ªÀgÀ £ÉÆÃAzÀt ¸ÀASÉå /Reg No:

Particulars of SSLC /equivalent examination passed. wAUÀ¼ÀÄ/Month: ªÀµÀð/Year:

11. ¤ÃªÀÅ L¹fJ¸ï/¹©J¸ï¹/L¹J¸ï¹AiÀÄ°è CzsÀåAiÀÄ£À ªÀiÁrzÀÝgÉ IGCSE/CBSE/ICSE /other

«ªÀgÀUÀ¼À£ÄÀ ß ¤ÃqÀĪÀÅzÀÄ:
If you have studied in IGCSE/CBSE/ICSE, give the details: Register No.

12. «PÀ®ZÉÃvÀ£À/CAzsÀvÀé/§Ä¢ÞªÀiÁAzÀå ºÉÆA¢ÝzÀgÉ zÁR¯ÉUÀ¼£

À ÄÀ ß ®UÀwÛ¹zÉAiÉÄà ºËzÀÄ/E®è
whether physically challenged/Blind/Mentally chanllenged Documents Enclosed Yes/NO
10£Éà vÀgÀUÀw/J¸ï.J¸ï.J¯ï.¹./vÀvÀìªÀiÁ£À vÀgÀUÀwAiÀÄ°è ¨sÁµÁ
«£ÁAiÀÄwAiÀÄ£ÀÄß ¥ÀqÉAiÀįÁVzÉAiÉÄÃ?
Whether Language Exemption is taken in 10th Std./SSLC/
Equivalent Examination. ºËzÀÄ/E®è Yes/No.
DVzÀÝ°è AiÀiÁªÀ «µÀAiÀÄUÀ½UÉ: 1.

If Yes, Subjects: 2.

¦AiÀÄĹ vÀgÀUÀwAiÀÄ°è AiÀiÁªÀ MAzÀÄ ¨sÁµÉUÉ «£Á¬Äw PÉÆÃgÀÄwÛ¢ÝÃj ?

Mention the language claimed for Exemption

13. C¨sÁå¸À ªÀiÁrzÀ «µÀAiÀÄUÀ¼ÀÄ Subjects ¥ÀqÉzÀ CAPÀUÀ¼ÀÄ/ ªÀiÁzsÀåªÀÄ/Medium

Marks obtained
st
1. ¥ÀæxÀªÀÄ ¨sÁµÉ/ 1 Language ¥sÀ°vÁA±À/ Result
nd
2. ¢éwÃAiÀÄ ¨sÁµÉ/ 2 Language
3. vÀÈwÃAiÀÄ ¨sÁµÉ/3rd Language
4. «eÁÕ£À/ Science ±ÉÃPÀqÀªÁgÀÄ CAPÀUÀ¼ÀÄ:

5. UÀtÂvÀ / Mathematics Percentage of Marks

6. ¸ÀªÀiÁd«eÁÕ£À/Social Science
¥ÀqÉzÀ MlÄÖ CAPÀUÀ¼ÀÄ/Total Marks obtained

14. QæÃqÉ/¥ÀoÉåÃvÀgÀ ZÀlĪÀnPÉUÀ¼À°è ¨sÁUÀªÀ»¹zÀÝ «ªÀgÀUÀ¼ÀÄ: vÁ®ÆèPÀÄ/f¯Áè/gÁdå ªÀÄlÖzÀ°è ¥Àæw¤¢ü¹zÀÝgÉ

zÁR¯ÉUÀ¼À ¥ÀæwUÀ¼À£ÄÀ ß ¸À°è¸ÀĪÀÅzÀÄ
Participation in Sports/ Extra Curricular activities: If Participated in Taluk/Dist./State
level submit the copy of the
Documents.

15. ¦AiÀÄĹAiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀ§AiÀĸÀĪÀ ¨sÁµÉUÀ¼ÀÄ ¨sÁUÀ- I/Part-I ¨sÁUÀ- II/Part-II

ªÀÄvÀÄÛ ¸ÀAAiÉÆÃd£É ¨sÁµÁ «µÀAiÀÄUÀ¼ÀÄ LaÑPÀ «µÀAiÀÄUÀ¼ÀÄ/Optional
Subjects Languages and Combination 1. 1
in the PU Course 2. 2.
3.
4.
14. ¦AiÀÄĹAiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀĪÀ ªÀiÁzsÀåªÀÄ PÀ£ÀßqÀ
Medium of Instruction in PU Course. English
 «zÁåyðAiÀÄ ªÀÄvÀÄÛ ¥ÉÆõÀPÀgÀ ªÀÄÄZÀѽPÉ / Student’s and Parent’s/Gaurdian’s undertaking:
1. £À£Àß PÁ¯ÉÃf£À ªÁå¸ÀAUÁªÀ¢üAiÀÄ°è E¯ÁSÉAiÀÄ J¯Áè DqÀ½vÀ/±ÉåPÀëtÂPÀ/¥ÀjÃPÁë ¤AiÀĪÀÄUÀ½UÉ §zÀÞ£ÁVgÀÄvÉÛãÉAzÀÄ
M¦àgÀÄvÉÛãÉ.
I here by accept that I will abide by the Administrative/Academic /Examination rules of the
Department during my study in the College
2. £Á£ÀÄ PÁ¯ÉÃf£À/E¯ÁSÉAiÀÄ J¯Áè PÁAiÀÄ9PÀæªÀÄUÀ¼À°è ²¹Û¤AzÀ £ÀqÉzÀÄPÉƼÀÄîvÉÛãÉAzÀÄ, MAzÀÄ ªÉÃ¼É C²¹Û¤AzÀ
ªÀwð¹zÀÝ°è/PÁ¯ÉÃf£À D¹Û¥Á¹ÛUÉ ºÁ¤ªÀiÁrzÀ°è CzÀjAzÁzÀ £ÀµÖª À À£ÀÄß £Á£Éà vÀÄA©PÉÆqÀĪÀÅzÁV M¦àgÀÄvÉÛãÉ.
I here by accept that during my stay in College, I will maintain discipline, and pay the damages
caused by me.
3. DvÀ£À ±ÉÊPÀëtÂPÀ ªÀÄvÀÄÛ ºÁdgÁw ¥ÀæUÀwAiÀÄ §UÉÎ PÁ®PÁ®PÉÌ PÁ¯ÉÃf¤AzÀ w½AiÀÄÄvÉÛãÉAzÀÄ, «zÁåyðAiÀÄ
C²¹Û¤AzÀ DzÀ £ÀµÀÖªÀ£ÀÄß vÀÄA© PÉÆqÀĪÀÅzÀPÉÌ §zÀÝ£ÁVgÀÄvÉÛãÉAzÀÄ M¦àgÀÄvÉÛãÉ.
I hereby accept that, I will ascertain the Academic/ Attendance progress of the Student from
time to time from the College and also pay the damages if any caused by the Student.

¸ÀܼÀ /Place: «zÁåy9AiÀÄ ¸À»/ vÁ¬Ä/vÀAzÉ/¥ÉÆõÀPÀgÀ ¸À»/

¢£Á0PÀ/ Date: Signature of the Student Signature of the Mother/Father/Gaurdian,

PÀbÉÃj G¥ÀAiÉÆÃUÀPÉÌ

zÁR¯Áw ¸ÀASÉå ____________ ±ÀÄ®Ì gÀÆ.____________gÀ¹Ãw ¸ÀASÉå___________¢£ÁAPÀ_______

«ÄøÀ¯Áw ªÀUÀð/ Reservation category:
¥ÀzÀ« ¥ÀƪÀð ²PÀët E¯ÁSÉAiÀÄ C£ÀĪÉÆÃzÀ£É ºÁUÀÆ ¤AiÀĪÀÄUÀ½UÉ §zÀÞªÁV, ºÁUÀÆ CUÀvÀå EgÀĪÀ J¯Áè ªÀÄÆ®
zÁR¯ÉUÀ¼À£ÀÄß ¸À°è¸ÀĪÀ µÀgÀwÛ£ÉÆA¢UÉ vÁvÁÌ°PÀÀªÁV zÁR¯Áw ªÀiÁrPÉƼÀî¯ÁVzÉ.

¢£ÁAPÀ: zÁR¯Áw ¸À«ÄwAiÀÄ ¸ÀzÀ¸ÀågÀ ¸À» ¥ÁæA±ÀÄ¥Á®gÀÄ ¸À»

¸ÀÆZÀ£ÉUÀ¼ÀÄ/Instructions
1. zÁR¯ÁwAiÀÄÄ vÁvÁÌ°PÀªÁVzÀÄÝ, E¯ÁSÉAiÀÄ C£ÀĪÉÆÃzÀ£ÉUÉ M¼À¥n
À ÖgÀÄvÀÛzÉ.
Admission to PUC is provisional & is subjected to Department approval.
2. CAPÀ¥ÀnÖ, ªÀÄÆ® ªÀUÁðªÀuÉ¥ÀvÀæ, 10£Éà vÀgÀUÀw ¥ÀjÃPÉë ¥ÀæªÉñÀ ¥ÀvÀæzÀ £ÀPÀ®Ä ¥Àæw eÁw ªÀÄvÀÄÛ DzÁAiÀÄ ¥ÀæªÀiÁt¥ÀvÀæ ºÁUÀÄ
EvÀgÉ zÁR¯ÉUÀ¼À zÀÈrüÃPÀj¹zÀ ¥ÀæwUÀ¼À£ÀÄß PÀqÁØAiÀĪÁV CfðeÉÆvÉ ¸À°è¸À¨ÉÃPÀÄ.ªÀÄÆ® ¥ÀæwUÀ¼À£ÀÄß zÁR¯Áw ¸ÀªÀÄAiÀÄzÀ°è
PÀqÁØAiÀĪÁV ¥Àj²Ã®£ÉUÉ ºÀÁdgÀÄ¥Àr¸À¨ÉÃPÀÄ.
Attested Xerox copies of SSLC/Equivalent exam Marks card/Transfer Certificate/ SSLC Hall ticket
Xerox copy /Caste & Income Certificate/Eligibility Certificate Issued by PU Department (If any)
Medical Certificate (if any) and any other Certificates must be submitted along with the
Application. All Original Certificates must be produced at the time of admission for verification.

__ ____ ____ ___ ____ ____ ____ ________ cut here ____ ___ ____ ____ ____ ____ ___
PÀĪÀiÁgÀ/ PÀĪÀiÁj ______________________________________ gÀªÀjAzÀ _____________________
¸ÀAAiÉÆÃd£ÉUÉ ¥ÀæxÀªÀÄ / ¢éwÃAiÀÄ ¦AiÀÄĹUÉ ¥ÀæªÉñÀ CfðAiÀÄ£ÀÄß ¥ÀqÉAiÀįÁVzÉ.
¸ÀܼÀ/Place:
¢£ÁAPÀ/ Date: Cfð ¹éÃPÀj¹zÀªÀgÀ ¸À»
 PÀÀ£ÁðlPÀ ¸ÀPÁðgÀ
¥ÀzÀ« ¥ÀƪÀð ²PÀët E¯ÁSÉ
PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉ Cfð (¨sÁµÉ/¸ÀAAiÉÆÃd£É §zÀ¯ÁªÀuÉAiÉÆA¢UÉ)
¨sÁUÀ 1 («zÁåyð ¨sÀwð ªÀiÁqÀ¨ÉÃPÀÄ)
¥ÀzÀ« ¥ÀƪÀð ²PÀëtzÀ ¥ÀæxÀªÀÄ / ¢éwÃAiÀÄ ªÀµÀðzÀ PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉ 2020-21
SATS NO: (EzÀÝ°è)
FUÀ C¨sÁå¸À ªÀiÁqÀÄwÛgÀĪÀ §zÀ¯ÁªÀuÉ §AiÀĹzÀ
PÁ¯ÉÃf£À ¸ÀAPÉÃvÀ ¸ÀASÉå: PÁ¯ÉÃf£À ¸ÀAPÉÃvÀ ¸ÀASÉå:
1 «zÁåyðAiÀÄ ºÉ¸ÀgÀÄ ªÀÄvÀÄÛ ¥ÀÆtð «¼Á¸À
2 C) «zÁåyðAiÀÄ vÁ¬ÄAiÀÄ ºÉ¸ÀgÀÄ
D) «zÁåyðAiÀÄ vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ
3 FUÀ ªÁå¸ÀAUÀ ªÀiÁqÀÄwÛgÀĪÀ vÀgÀUÀw (nPï ªÀiÁr) ¥ÀæxÀªÀÄ ¦AiÀÄĹ / ¢éwÃAiÀÄ ¦AiÀÄĹ
4 §zÀ¯ÁªÀuÉ ºÉÆAzÀ®Ä §AiÀĹgÀĪÀ vÀgÀUÀw (nPï ªÀiÁr) ¥ÀæxÀªÀÄ ¦AiÀÄĹ / ¢éwÃAiÀÄ ¦AiÀÄĹ
5 ¥ÀæxÀªÀÄ / ¢éwÃAiÀÄ ¦AiÀÄĹ N¢zÀ ªÀµÀð
6 «zÁåyðAiÀÄÄ »AzÉ C¨sÁå¸À ªÀiÁrgÀĪÀ «µÀAiÀÄ ºÁUÀÆ §zÀ¯ÁªÀuÉ ªÀiÁqÀ®Ä GzÉÝò¹zÀ «µÀAiÀÄ ºÁUÀÆ
¸ÀAAiÉÆÃd£É ¸ÀAAiÉÆÃd£É
¸ÀAPÉÃvÀ ¸ÀAPÉÃvÀ
PÀæ.¸ÀA ¨sÁµÉUÀ¼ÀÄ/«µÀAiÀÄUÀ¼ÀÄ PÀæ.¸ÀA ¨sÁµÉUÀ¼ÀÄ/«µÀAiÀÄUÀ¼ÀÄ
¸ÀASÉå ¸ÀASÉå
1 1
2 2
3 3
4 4
5 5
6 6
7 PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉUÉ ªÀÄÄRå PÁgÀt:
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ªÉÊzÀåQÃAiÀÄ ¥ÀæªÀiÁt ¥ÀvÀæ ¸À°è¸ÀĪÀÅzÀÄ)
2. vÀAzÉ/vÁ¬ÄAiÀĪÀgÀ ºÀÄzÉÝ ªÀUÁðªÀuÉ(ªÀUÁðªÀuÉ DzÉñÀzÀ ¥Àæw
¸À°è¸ÀĪÀÅzÀÄ)
3. ªÀÄ£É §zÀ¯ÁªÀuÉ (¸ÀA§A¢ü¹zÀ zÁR¯ÉUÀ¼À£ÀÄß ¸À°è¸ÀĪÀÅzÀÄ)
9 ±ÀÄ®Ì ¥ÁªÀw ªÀiÁrzÀ «ªÀgÀUÀ¼ÀÄ:
PÁ¯ÉÃdÄ PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉ ±ÀÄ®Ì: gÀÆ. 1600/- ZÀ®£ï ¸ÀASÉå:
¸ÀAAiÉÆÃd£É §zÀ¯ÁªÀuÉ ±ÀÄ®Ì: gÀÆ. 800/- ¢£ÁAPÀ:
§zÀ¯ÁªÀuÉ §AiÀĹzÀ PÁ¯ÉÃf£À ¥ÁæA±ÀÄ¥Á®gÀÄ Online ªÀÄÆ®PÀ
C£ÀĪÀÄw¹zÀ £ÀAvÀgÀ K-2 ZÀ®£ï ªÀÄÆ®PÀ ºÀt ¥ÁªÀw¸ÀĪÀÅzÀÄ) ¯ÉPÀÌ
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(ºÀt ¥ÁªÀw¹zÀ ªÀÄÆ® ZÀ®£ï ¸À°è¸ÀĪÀÅzÀÄ)

vÀAzÉ/¥ÉÆõÀPÀgÀ ¸À» «zÁåyðAiÀÄ ¸À»

«zÁåyðUÉ E¯ÁSɬÄAzÀ ¤ÃqÀ¯ÁzÀ «zÁåyð ¸ÀASÉå
Student Number (Online portal ªÀÄÄSÁAvÀgÀ ¥Àqz
É À ¸ÀASÉå)

«zÁåyðAiÀÄÄ MzÀV¹zÀ «ªÀgÀUÀ¼À£ÀÄß RÄzÀÄÝ ¥Àj²Ã°¹gÀÄvÉÛãÉ. «ªÀgÀUÀ¼ÀÄ ¸ÀjAiÀiÁVgÀÄvÀÛzÉ.

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PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉUÉ ²¥sÁgÀ¸ÀÄì ªÀiÁrzÉ.
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PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉ Cfð (PÉêÀ® PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉUÉ ªÀiÁvÀæ)
¨sÁUÀ 1 («zÁåyð ¨sÀwð ªÀiÁqÀ¨ÉÃPÀÄ)
¥ÀzÀ« ¥ÀƪÀð ²PÀëtzÀ ¥ÀæxÀªÄÀ / ¢éwÃAiÀÄ ªÀµÀðzÀ PÁ¯ÉÃdÄ §zÀ¯ÁªÀuÉ 2020-21
SATS NO: (EzÀÝ°è)

FUÀ C¨sÁå¸À ªÀiÁqÀÄwÛgÀĪÀ §zÀ¯ÁªÀuÉ §AiÀĹzÀ

PÁ¯ÉÃf£À ¸ÀAPÉÃvÀ ¸ÀASÉå: PÁ¯ÉÃf£À ¸ÀAPÉÃvÀ ¸ÀASÉå:
1 «zÁåyðAiÀÄ ºÉ¸ÀgÀÄ ªÀÄvÀÄÛ ¥ÀÆtð «¼Á¸À:
ºÁUÀÆ ªÉƨÉÊ¯ï ¸ÀASÉå (zÀ¥Àà CPÀëgÀUÀ¼À°è)
2 C) «zÁåyðAiÀÄ vÁ¬ÄAiÀÄ ºÉ¸ÀgÀÄ
D) «zÁåyðAiÀÄ vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ
3 «zÁåyðUÉ E¯ÁSɬÄAzÀ ¤ÃqÀ¯ÁzÀ «zÁåyð
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 GOVERNMENT OF KARNATAKA
DEPARTMENT OF PRE-UNIVERSITY EDUCATION

APPLICATION FOR LANGUAGE EXEMPTION IN PART-1 for PUC Students (2020-21)

SL. PARTICULARS INFORMATION TO BE PROVIDED
NO
1 Name of the Student
(in block letters)
2 Name of the Mother
(in block letters)
3 Name of the Father
(in block letters)
4 Name and address of the College

5 SSLC/10th standard Register number a)

and year of passing.(Enclose Xerox
attested Markscard) b)
6 Reasons for claiming exemption
(Details with present studying
class,Combination and Medium )
(ex 1st PUC, PCMB & Eng )
7 Documents to be enclosed:

a) Attested copy of the marks card. a) Attested/Not attested

b)Attested copy of Exemption order issued b) Attested/Not attested
for language exemption in SSLC/10th c) Attested/Not attested
standard.
c) Attested copy of the Medical Certificate

8 Residential Address of the Student

(in block letters)

Place:
Date: Signature of the Student.

The above student may be given exemption from studying ……………………………………….

Language in 1st and 2nd PUC.

Place:
Date:

GOVERNMENT OF KARNATAKA
DEPARTMENT OF PRE-UNIVERSITY EDUCATION

APPLICATION FOR ISSUE OF MIGRATION CERTIFICATE (2020-21)

 Name of the student
01
(in block letters)
Father ‘s name
02
(in block letters)
Name of the institution last
03
Attended

Examination passed with

04 Reg. No. and year of passing
and combination studied

Prescribed fee of Rs 480-00 (Four hundred and

Eighty only) has to be remitted to Head of Account Challan No.
-
Dated
“0202 Education Sports, arts & culture
05 01 General education, 102 secondary Education, 1 Remitted at
Tution and other Fees
07 Examinaion fees of junior colleges
Is enclosed.
(HOA: 0202-01- 102-1-06)
(Original challan to be enclosed)

06 Reason for Migration

Whether attested copies of following

documents enclosed:

07 1. Marks card/Marks statement

2. Transfer certificate/no due certificate
issued by the Head of the Institution

Address of the student

08
(in block letters)

Place :
Date :
SIGNATURE OF THE STUDENT

GOVERNMENT OF KARNATAKA

DIRECTORATE OF PRE-UNIVERSITY EDUCATION

APPLICATION FOR THE ISSUE OF ELIGIBILITY CERTIFICATE (2020-21)
(Read the instructions before filling the application form)
 Name of the student with Previous college address.
01
(in block letters)
Father’s name
02
(in block letters)
03 Nationality

Residential address:
04
a) In your Country (applicable to foreign students)

b) In India

Qualifying examination
a) Name of the Examination with Register No
05
(Name of the examining body/University
b) Year of schooling

Whether seeking admission to

06 I YEAR PUC / II YEAR PUC
(Tick whichever applicable)
07 Stream of course of study (tick mark) SCIENCE / COMMERCE / ARTS
Names of 3 Colleges in order 1)

08 of preference where candidate 2)

desire to seek admission 3)

09 Fees remitted Challan No ............... Date.......................

Attested testimonials and other required documents to be enclosed

with this application:
i) Statement of marks certificate of the qualifying examination
passed.
10 ii) Transfer Certificate,
iii) Bonafide certificate
iv) Migration Certificate issued by the head of the institution
where the student attended previously. From university / board.
v) Photocopy of passport & visa in case of foreign Student.

11 Any other information the student wishes to furnish

Certified that the information furnished above is true and correct to the best of my knowledge and
belief.

Place :
Date :
SIGNATURE OF THE STUDENT

INSTRUCTIONS (ELIGIBILITY CERTIFICATE)

The rate of eligibility fee shall be is Rs 4750-00 per certificate in case of foreign and
NRI’s and Rs 1000-00 per certificate to the students who qualify an equivalent examination
conducted by a Board / University or autonomous body within India (Except for Students
from Karnataka State Education Examination Board).
 1. The mode of payment of fee shall be through challan. Head of A/c to remit the
fees are as follows.

0202 - Education arts sports and culture,

01 - General education
102 - Secondary Education
1 - Tuition and other fees
06 - Tution fees of Junior colleges and other fees
Code No 0202-01-102-1-06

2. The original certificate of qualification and other requisite documents along with
one photocopy of each shall invariably to be enclosed with the application, the original shall
be returned while issuing provisional eligibility certificate.

3. The information called for in the application should be complete and correct.
Incomplete applications are liable for rejection.

4. The candidate seeking provisional eligibility certificates for admission to II year

PUC will have to enclose a copy of tenth grade examination in addition to eleventh grade
examination.

5. Any other information pertaining to qualifying examination, bonafide certificate

and migration certificate and rules thereof would essentially required of a candidate, shall
have to furnished at once, when called upon before issuing the provisional eligibility
certificate.

****