FIRST YEAR UG/PG ADDMISSION APPLICATION FORM 2015-16

REGISTER NUMBER:

NOT ALLOTED

APPLICATION NO.

KU150105384

NAME

NAZEEMA

FATHER NAME

DHASTHAGEER SAB

DATE OF BIRTH : 11/7/1980

CATEGORY: 2B

GENDER : FEMALE |

HANDICAP: NONE |

OCCUPATION:DAILY WAGER WORKER

NATIONALITY: INDIAN

ANNUAL INCOME: 11000

ADDRESS: BADRAKALI TEMPLE OPP, HK ROAD, UPPALI CHIKKAMGLAURU, CHIKKAMGLAURU, 577101,

KARNATKA

PHONE: 9164944404

| EMAIL: webcomno1@gmail.com

COURSE DETAILS

GRADUATION: PG

MEDIUM: KANNADA

COURSE: MA

SUBJECT :SOCIOLOGY |

COURSE CODE :PGH13

LANGUAGES/ELECTIVES:

SL

PAPER TITLE

PAPER CODE

PAPER TYPE

Development of Sociological Thought

56661

COMPULSORY

Research Methodology

56662

COMPULSORY

Social Statification & Mobility

56663

COMPULSORY

Sociology of Education

56664

COMPULSORY

CENTER DETAILS
STATE : KARNATKA |
DISTRICT : CHIKKAMGLAURU
CENTER NAME : CHIKMAGALUR:46-MOUNTAIN VIEW ACADEMY, CHIKMAGALUR

CENTRE CODE : 46

FEE DETAILS
PAYMENT MODE:SBM CHALLAN
PAYMENT DATE:

| AMOUNT: Rs.6600/|

REFERENCE NO:

SBM BRANCH:

DATE : 18-11-2015
PLACE :

Signature of the Applicant

P.T.O.

Page-2

DECLARATION

I hereby solemnly and sincerely affirm that the statements made and information furnished in my application and also in
the enclosures submitted by me are true. Should it, however be found that the information furnished therein is not
factually true, I know that I am liable for prosecution and forfeiture of my admission. I have also taken note that once the
admission process is over, fee shall not be refunded by the university. In case of my grievances, I shall approach the
university and in case of any arbitration and any redressal of grievances I shall abide by the arbitration and territorial
jurisdiction clause laid in the prospectus.

Place :

Date :

Signature of the Applicant

Note: Candidates should send the filled up Application to the Director, DDE, Kuvempu University, Jnana Sahyadri,
Shankaraghatta 577451, Shimoga District, Karnataka along with the SBM Challan / N.E.F.T. Form and Relevant
Documents.

KUVEMPU

KUVEMPU

UNIVERSITY

UNIVERSITY

KUVEMPU

UNIVERSITY

DIRECTORATE OF DISTANCE EDUCATION

Jnana Sahyadri, Shankaraghatta-577451, Shimoga(D), Karnataka
CHALLAN

DIRECTORATE OF DISTANCE EDUCATION

Jnana Sahyadri, Shankaraghatta-577451, Shimoga(D), Karnataka
CHALLAN

DIRECTORATE OF DISTANCE EDUCATION

Jnana Sahyadri, Shankaraghatta-577451, Shimoga(D), Karnataka
CHALLAN

Bank Copy

DDE Copy - To be sent with application form

Student Copy - To be retained with applicant

S.B.M POWER JYOTHY A/C NO. :64100999567

STATE BANK OF MYSORE, JNANASAHYADRI BRANCH
BRANCH CODE : 40759 IFSC CODE : SBMY0040759

S.B.M POWER JYOTHY A/C NO. :64100999567

STATE BANK OF MYSORE, JNANASAHYADRI BRANCH
BRANCH CODE : 40759 IFSC CODE : SBMY0040759

S.B.M POWER JYOTHY A/C NO. :64100999567

STATE BANK OF MYSORE, JNANASAHYADRI BRANCH
BRANCH CODE : 40759 IFSC CODE : SBMY0040759

BANK USE ONLY

BANK USE ONLY

BANK USE ONLY

Bank

Bank

STATE BANK OF MYSORE

STATE BANK OF MYSORE

Bank

Branch Name

Branch Name

Branch Name

Branch Code

Branch Code

Branch Code

Journal NO.

Journal NO.

Journal NO.

Date

Date

Date

Reference NO. :

KU150105384

Reg NO.: NOT ALLOTED

Reference NO. :

KU150105384

Reg NO.: NOT ALLOTED

STATE BANK OF MYSORE

Reference NO. :

KU150105384

Reg NO.: NOT ALLOTED

Applicant Name: NAZEEMA

Applicant Name: NAZEEMA

Applicant Name: NAZEEMA

Address : BADRAKALI TEMPLE OPP, HK ROAD, UPPALI

CHIKKAMGLAURU, CHIKKAMGLAURU, 577101, Karnatka

Address : BADRAKALI TEMPLE OPP, HK ROAD, UPPALI

CHIKKAMGLAURU, CHIKKAMGLAURU, 577101, Karnatka

Address : BADRAKALI TEMPLE OPP, HK ROAD, UPPALI

CHIKKAMGLAURU, CHIKKAMGLAURU, 577101, Karnatka

Course

Course

Course

MA
Fee Paid :

Subject

Fee

SOCIOLOGY

Rs.6600/-

MA
Fee Paid :

6600

Subject

Fee

SOCIOLOGY

Rs.6600/-

6600

MA
Fee Paid :

Subject

Fee

SOCIOLOGY

Rs.6600/-

6600

Amount In Words : Six Thousand Six Hundred Only

Amount In Words : Six Thousand Six Hundred Only

Amount In Words : Six Thousand Six Hundred Only

PAID TO THE CREDIT OF FINANCE OFFICER, KUVEMPU UNIVERSITY, SHANKARAGHATTA,

SHIMOGA (D), KARNATAKA

PAID TO THE CREDIT OF FINANCE OFFICER, KUVEMPU UNIVERSITY, SHANKARAGHATTA,

SHIMOGA (D), KARNATAKA

PAID TO THE CREDIT OF FINANCE OFFICER, KUVEMPU UNIVERSITY, SHANKARAGHATTA,

SHIMOGA (D), KARNATAKA

A/C NO :64100999567 WITH SBM,JNANASAHYADRI SHANKARAGHATTA SHIMOGA

A/C NO :64100999567 WITH SBM,JNANASAHYADRI SHANKARAGHATTA SHIMOGA

A/C NO :64100999567 WITH SBM,JNANASAHYADRI SHANKARAGHATTA SHIMOGA

Particulars

Particulars

Particulars

Amount

Course Fee
Rs.6600/-

Bank Charges
Rs.50/-

Total
Rs.6650/-

Amount

Course Fee
Rs.6600/-

Bank Charges
Rs.50/-

Total
Rs.6650/-

Amount

Course Fee
Rs.6600/-

Bank Charges
Rs.50/-

Total
Rs.6650/-

Amount In Words :Six Thousand Six Hundred Fifty Only

Amount In Words :Six Thousand Six Hundred Fifty Only

Amount In Words :Six Thousand Six Hundred Fifty Only

Date :

Date :

Date :

Signature of the Remitter

Signature of the Remitter

Signature of the Remitter

Received Rupees

Received Rupees

Received Rupees

Date & Seal

Signature of the Receiver
1. Accepted at all the branches of SBM
2. Collecting Branch has to enter Reference No : & Name of the Candidate
for this transaction in core Banking System
3. Not Transferable.

Date & Seal

Signature of the Receiver
1. Accepted at all the branches of SBM
2. Collecting Branch has to enter Reference No : & Name of the Candidate
for this transaction in core Banking System
3. Not Transferable.

Date & Seal

Signature of the Receiver
1. Accepted at all the branches of SBM
2. Collecting Branch has to enter Reference No : & Name of the Candidate for
this transaction in core Banking System
3. Not Transferable.