Form- A g AS/Receipt No:

t:c ... c . c.o./ t .:: ; For College use only cc.o... ... c:. / =;
.t. c. ;Acknowledgement Number Combination Reservation category


t .:=.t t:=c ; Government of Karnataka
. o = :t ~ :c...t: .c..; Commissionerate of Pre-University Education
x Ai zRw Cf/ I PUC Admission Application Form 2012-13
t .c . c.o./ t:^ .:: ; For Office use only
2012-13 1. ::c:. c.; Admission No
2. .: / -. - cc.o... ;Languages cum- combination.
. .:.; Medium KM EM
+. ..:/ ; Section
5. ... c:. / =; Reservation category

l. .:=c.. o~= c. ;
Name of the Student in English
as entered in SSLC marks card
(CAPITAL LETTERS ONLY).
2. .. :.:ct ; DAY MONTH YEAR.
DATE OF BIRTH
3. l. .=;Religion.
2. ::. / Caste
3. . ::. / Sub Caste
4. .:=c.. .:c..c .-: ;Permanent Address. :ct .-: ; Correspondence Address
.-:
Address
Tel No/Mobile No:
5. .:=c.. :::. .:. : c c.. c. :::.; Mother
Name of the parents : c ; Father
6. :::. .:. : c .. c: :^. : . c .; Name
o. t c c. .:. .-: c.c ; Relationship.
If Parents are not alive,
Name of the Guardian and relationship with address
. o. t c :.=t ::c.. ::c. . .:~ : ./ . c. .:; yes
Parents Annual Income Is income certificate enclosed No
. = .c : c/ .:. ::c:;t:c ... c. .:. .-:
Name and address of the school /college last studied.
9. : ./ = c..: ...c;: : .:. c.t: . c . .o.c ~ c. /Reg number:
Particulars of SSLC /equivalent examination passed. =; Year: .c/ -.; Month
10 -.: .:. . c../ -.; Subjects studied -ct / -. .:.
Marks obtained Medium
l. ; . .: ; 1
st
Language __________________________________ .::c: Result
2. :..c.. .: ; 2
nd
Language ......................................
. :..c.. .: ;3
rd
Language___________________________________
4..::. ; Science ___________________________________ : .t :c. -ct / - .
./ ~ : ; Mathematics __________________________________ Percentage of marks
:. .:. .:: . ; Social Science_________________________________
... -ct / -.; Total marks obtained
.. .... .... ... .... .... .... ........ cut here .... ... .... .... .... .... ....
:.:ct
.:=c.. c.


.t. c.
cc.o...


... c:. / =;Reservation category
.t c c . .:. t:c ... o c. c :.: c.;Receipt No:




.t. :


:. ... . : .: ..
-c.
Affix recent
pass port size
photograph


:

ll - . ; c.: c ...t / - . .:/ .c c.c: : : / - . .t c ./ . c..:;
: c:t ./ - .. ./ . ... Is enclosed
If You have participated in sports/ extra curricular activities, enclose attested -. Yes
photo copies of the certificates. :. ; No

12 .c...c... : c/ .: .c... .: / -. .:/ - I;Part-I .:/ - II ;Part-II
.:. cc.o... .:: . c../ -. :. t . c../ -./Opt. subjects
Languages and Combination intended 1. 1.
For study in the PU Course 2. 2.
3.
4.
l. .c...c... : c/ .:. .: . t . :c^ .
Medium of instruction in PU Course. Kannada English

.:=c.. ZP ; Students undertaking.
l. . . t:c ... : c/: : c... :c...t: .c.. .c: : -: ;:t ~ t ; c.t: c.../ -/ ..:^c.: .. c.
..c.: .. .
I here by accept that I will abide by the Administrative/Academic /Examination rules of
the Commissionerate during my study in the college
.:.. t:c ... ;:c:. c.. .c: t:c..t ./ - . : c . .to-. : .. c., .c. .- -: c
.=. ;t:c ... : : / :.:. . - cc: . .. .:. . :.c.to.:^ .. c.: .. .
I here by accept that during College/Commissionerate activities, I will maintain
discipline, and pay the damages caused by me.
!. t:c ... ;:c:. c.. t:c..= ...t / - . c. .. :t t / -/ t:c ...;:c:. .:.:c :/.:.
.c.. .. ..: ..
College/Commissionerate is not be responsible for any eventuality that may happen during any
event.
/Place:
0P/ Date: zy9Ai /
Signature of the Student

Pg .. -t ; Parents/Guardians undertaking.
l. : c/: : c... .... .:=c... .- c.. . : :.c:., :c...t: .c.. .c: : -: ;:t ~ t
c.../ -/ ..:^c.:: . c. .. c.: ..
I here by accept that the above student will abide by all the (Administrative & Academic)rules of
the Commissionerate
!. :: . :t ~ t .:. :.c:. / .c.. ./ t:.t:.t t:c ..c .-c...: .. c., .:=c.. -: c
: . .. :.c. to. t ..:^c.: .. c. ..c.: .. .
I here by accept that, I will know the Academic/Attendence progress of the student from time to
time from the college and also pay the damages if any caused by the Student.
/Place:
0P/ Date: :::.;: c ;o. t c .;
Signature of the Mother/Father/Guardian,


t .c . c.o./ t
::c:. c. ............ :.. co ............c .. c............:.:ct ........
::c:. ...c.. c .

. o = :t ~ :c:. c.. -..o. . :/o c.../ -/ .:^, :/o -/ : :c. .c:
.o. ::c / - .. . . c . .oc:/ ::::.t :^ ::c:. .:.to-c:^ .
:.:ct : c:.:.c. .

ZU/Instructions
l.::c:.c... ::::.t :^., :c...t: .c.. -..o. . / .- .c .: .
Admission to PUC is provisional & is subjected to Commissionerates approval.
!.-ct ., .o. /:= : , ::. .:. ::c.. .:~ : :/. :: c ::c / - . .t c
./ - .. t : c..:^ -.=:o: . . .t..
Attested Xerox copies of SSLC/Equivalent exam Marks card/Transfer Certificate/Caste & Income Certificate/Eligibility
Certificate Issued by PU commissionerate (If any )/Medical certificate (if any} and any other Certificates must be
submitted along with the application.
..::c / - .c: .o. ./ - .. ::c:. .c.. . t : c..:^ c:... / :.c. . . .t..
All Original Certifictes must be produced at the time of admission for verification.
+ .-o~= .:..c.. -.=/ - .. .c c c:/..; Incomplete applications will be rejected.