UNIVERSITY

OF MYSORE

MYSORE, KARNATAKA 570005

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Passport
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APPLICATION FORM 2014 2015

___________________________________________________________________________________________________________________________
PROGRAM ENROLLED FOR:
___________________________________________________________________________________________________________________________
STUDENT PERSONAL INFORMATION (PLEASE FILL IN BLOCK LETTERS)
1. NAME

_________________________________________________________________________________________________________
(FIRST NAME)

(MIDDLE NAME)

2. ROLL NO. (For office use only)

(LAST NAME)

_______________________________________________________________________________

3. DATE OF BIRTH

_________________________________________

4. STATE

5. PLACE OF BIRTH

_________________________________________

6. MOTHER TOUNGE __________________________

(As Per Marks Card)

7. GENDER _________________

___________________________________

8. NAME OF FATHER/GUARDIAN/HUSBAND ____________________________________

9. NAME OF MOTHER ___________________________

10. NATIONALITY

___________________________________

11. POSTAL ADDRESS OF APPLICANT _______________________________________________________________________________

___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________

12. CONTACT NUMBERS:

(With STD Code)

(1) OFFICE _________________________

(2) MOBILE _____________________________

(3) RESIDENCE ___________________

(4) E-MAIL ______________________________

13. CATEGORY __________________________________________ 14. ANNUAL INCOME ___________________________________

15. WHETHER __________________________________________ 16. ADMISSION CYCLE ___________________________________

17. Qualifying Examination Passed:

Examination Passed

Subject
Opted

Board/University

Reg. No. & Year

of Passing

Marks
Obtained

% of
Marks

Class
Obtained

18. APPLICANTS PROFESSION ________________________________________________________________________________________

19. WORK EXPERIENCE
Overall Work Experience: ________________ Years
List all organizations that you have worked with, starting with the current one. (If required, use separate sheet)
Company Address

Designation

Experience
From
To

Job Responsibility

20. FEE PAYMENT DETAILS (If payment done online, please share the transaction ID)
SL.NO.

TYPE OF FEE

1.

Application Fee

2.

Registration Fee

3.

Program Fee

4.

Examination Fee

AMOUNT (`)
FEE PAID D.D. NO. _______________________________
DATED ____________________________________________
BRANCH OF REMITTANCE
____________________________________________________
NAME OF BANK
____________________________________________________

TOTAL

I declare that the information furnished above by me is correct to the best of my knowledge. I also
understand that if any of my above statements are found to be untrue, I may be disqualified from the
course. I undertake that I shall abide by the rules and regulations of the University.
SPECIMEN SIGNATURE
Place:
Date:

1. __________________________________

2. _________________________________________
Signature of Applicant