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 2017-18
PÀbÉÃj G¥ÀAiÉÆÃUÀPÁÌV ªÀiÁvÀæ / For Office use only EwÛÃa£À ¨sÁªÀ avÀæªÀ£ÀÄß
CAn¹
1. zÁR¯Áw ¸ÀASÉå/ Admission No
Affix recent
2. ¨sÁµÉUÀ¼ÀÄ –ªÀ-¸ÀAAiÉÆÃd£É/Languages –cum- combination. pass port size
3. ªÀiÁzsÀåªÀÄ/ Medium PÀ£ÀßqÀ/Kannada EAVèõï/English photograph
4. «¨sÁUÀ/ Section
5. «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 / DATE OF BIRTH DAY MONTH YEAR.

2.b) °AUÀ/Gender : ¨Á®Q/Girl or ¨Á®PÀ/Boy

2. c) ºÀÄnÖzÀ ¸ÀܼÀ gÁdå f¯Éè vÁ®ÆèPÀÄ
place of birth State District Taluk
3.a)Nationality/gÁ¶ÖçÃAiÀivÉ b)zsÀªÀÄð/Religion. c). eÁw/Caste: 3.)G¥ÀeÁw / Subcaste:
4.«zÁåyðAiÀÄ SÁAiÀÄA «¼Á¸À/Permanent Address. ¸ÀܽAiÀÄÀ«¼Á¸À/Local Address
«¼Á¸À
Student’s Address
Tel No/Mobile No: Aadhar No:
5. «zÁåyðAiÀÄ vÀAzÉ ªÀÄvÀÄÛ vÁ¬Ä/¥Á®PÀgÀ ºÉ¸ÀgÀÄ: vÁ¬Ä/ Mother
Name of the Parents/Guardian : vÀAzÉ/ Father
6. ¥ÉÆõÀPÀgÀ/¥Á®PÀgÀ «¼Á¸À:
Address of the Parents/Gaurdian :

7. ¥ÉÆõÀPÀgÀ/¥Á®PÀgÀ ªÁ¶ðPÀ DzÁAiÀÄ : DzÁAiÀÄ ¥ÀæªÀiÁt¥ÀvæÀ ®UÀwÛ¹zÉAiÀiÁ?ºËzÀÄ/E®è

Parents /GuardianAnnual Income : Is Income Certificate enclosed yes/ No
8. F »AzÉ ªÁå¸ÀAUÀ ªÀiÁrzÀ ±Á¯Á/PÁ¯ÉÃf£À ºÉ¸ÀgÀÄ ªÀÄvÀÄÛ «¼Á¸À
Name and address of the School /College last studied.

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

Particulars of SSLC /equivalent examination passed. ªÀµÀð/Year: wAUÀ¼ÀÄ/month
10. «PÀ®ZÉÃvÀ£À/CAzÀvÀé/§Ä¢ÝªÀiÁAzÀå ºÉÆA¢ÝzÀgÉ zÁR¯ÉAiÀÄ£ÀÄß ®UÀwÛ¹zÉAiÉÄà ºËzÀÄ/E®è
If whether Physically challenged/Blind/Mentally chanllenged Documents Enclosed Yes/NO

__ _ _ _ _ _ _ _ _ _ _ cut here _ _ _ _ _ _ _
PÀĪÀiÁgÀ/ PÀĪÀiÁj _ _ _ _ gÀªÀjAzÀ _ _ _
¸ÀAAiÉÆÃd£ÉUÉ ¥ÀæxÀªÀÄ / ¢éwÃAiÀÄ ¦AiÀÄĹUÉ ¥ÀæªÉñÀ CfðAiÀÄ£ÀÄß ¥ÀqÉAiÀįÁVzÉ.
¸ÀܼÀ/Place:
¢£ÁAPÀ/ Date: Cfð ¹éÃPÀj¹zÀªÀgÀ ¸À»
[
11 C¨sÁå¸À ªÀiÁrzÀ «µÀAiÀÄUÀ¼ÀÄ Subjects ¥ÀqÉzÀ CAPÀUÀ¼ÀÄ Marks obtained ªÀiÁzsÀåª ÀÄ/Medium
st
1. ¥ÀæxÀªÀÄ ¨sÁµÉ/ 1 Language ¥À°
s vÁA±/À Result
nd
2. ¢éwÃAiÀÄ ¨sÁµÉ/ 2 Language
rd
3. vÀÈwÃAiÀÄ ¨sÁµÉ/3 Language
4. «eÁÕ£À/ Science ±ÉÃPÀqÀªÁgÀÄCAPÀUÀ¼ÀÄ:

5. UÀtÂvÀ / Mathematics Percentage of Marks

6. ¸ÀªÀiÁd«eÁÕ£À/Social Science
¥ÀqÉzÀ MlÄÖ CAPÀUÀ¼ÀÄ/ Total Marks obtained
12 .QæÃqÉ/ ¥ÀoÉåÃvÀgÀ ZÀlĪÀnPÉUÀ¼À°è ¨sÁUÀªÀ»¹zÀÝ «ªÀgÀUÀ¼ÀÄ:
Participation in Sports/ Extra Curricular activities:
13. ¦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 offered 1. 1
to study in the PU Course 2. 2.
3.
4.
14. ¦AiÀÄĹAiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀĪÀ ªÀiÁzsÀåªÀÄ PÀ£ÀßqÀ EAVèõï
Medium of instruction in PU Course. Kannada English
15 .«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 £ÀµÀÖªÀ£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,

16. PÀbÉÃj G¥ÀAiÉÆÃUÀPÉÌ

zÁR¯Áw ¸ÀASÉå _ _ ±ÀÄ®Ì gÆÀ _ g¹
À Ãw s¸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¥ÀnÖgÀÄvÀÛzÉ.
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 ¥æÀªÀiÁt¥ÀvÀæ ºÁUÀÄ EvÀgÉ zÁR¯ÉUÀ¼À
zÀÈrüÃPÀj¹zÀ ¥ÀæwUÀ¼À£ÀÄß PÀqÁØAiÀÄ ªÁV 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.
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