Karnataka State Road Transport Corporation

(Application for Student Bus Pass)

Affix the Photograph
attested by the Head of the
Divisional Controller, Institution.

K.S.R.T.C,
…………………………Division. Passport Size
Photo

Name (IN BLOCK LETTERS)...........................................................................

Father’s Name .....................................................................................................
Date of Birth.........................................................Class................................
Primary/ Middle school High school College/Degree Diploma/Professional/ITI
Educational Institution Name / address :……………………………………………..
………………………………………………………………………….
Gender : Male Female .
Aadhaar No ..............................................................................
Category : GM Other (OBC) SC ST
Permanent Address……. ...................................................................................................
…….......................................................................................................................
Temporary Address :…………………………………………………..
…………………………………………………………………………..
Pass Route: From ………………………. …….To ………………………………..
Route change place………………………………………………………………….
Pass Duration: From ………………….……..To ………………… ……………..
School/college fee Receipt No.……… …………....Date……………….………

I will not misuse this pass.

Parent/Guardian Signature Student Signature

Date:
…………………………………………………………………………………………
Confirmation from Educational Institution
The above information is correct. It is certified that students’ personal details mentioned
above are as recorded in our Education Institution.

Student Registration No.:…………………………………………..

Principal/Head Master/ School/College/University Seal

Head mistress Signature Date:
…………………………………………………………………………………………
For office use only
Pass / Card No………………………….….
Validity of pass ………….. to ………………
Chargeable stages ………………………………
Printed at : KST press, B’lore
 PÀ£ÁðlPÀ gÁdå gÀ¸ÉÛ ¸ÁjUÉ ¤UÀªÀÄ
(«zÁåy𠧸ï¥Á¸ïUÁV Cfð)
«zÁå¸ÀA¸ÉÜAiÀÄ ªÀÄÄRå¸ÀÜjAzÀ
zÀÈrüÃPÀj¹gÀĪÀ
¨sÁªÀavÀæªÀ£ÀÄß ®UÀwÛ¸ÀĪÀÅzÀÄ.
«¨sÁUÀ ¤AiÀÄAvÀæuÁ¢üPÁjAiÀĪÀjUÉ,
¥Á¸ï¥ÉÆÃmïð
PÀ.gÁ.gÀ.¸Á ¤UÀªÀÄ,
C¼ÀvÉAiÀÄ ¨sÁªÀavÀæ
..............................................«¨sÁUÀ.

ºÉ¸ÀgÀÄ ...................................................................................................................................
vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ ...................................................................................................................................................
ºÀÄnÖzÀ ¢£ÁAPÀ.............................................................. vÀgÀUÀw ....................................
¥ÁæxÀ«ÄPÀ/ ªÀiÁzsÀå«ÄPÀ ±Á¯É ¥ËæqsÀ±Á¯É PÁ¯ÉÃdÄ/¥ÀzÀ« r¥ÉÆèªÉÆ/ªÀÈwÛ¥ÀgÀPÁ¯ÉÃdÄ/LnL
«zÁå¸ÀA¸ÉÜ ºÉ¸ÀgÀÄ & «¼Á¸À: ..................................................................................
............................................................................... ..................................................................................
°AUÀ: UÀAqÀÄ ºÉtÄÚ
DzsÁgï ¸ÀASÉå ...................................................................................................................................................
ªÀUÀð: ¸ÁªÀiÁ£Àå EvÀgÉ(N©¹) ¥À.eÁw ¥À.¥ÀAUÀqÀ
SÁAiÀÄA «¼Á¸À :.............................................................................................
........................................................................................................................................................
vÁvÁÌ°PÀ «¼Á¸À:............................................................................................................................
.................................................................................................................................................................
¥Á¸ï ¨ÉÃPÁVgÀĪÀ ªÀiÁUÀð...........................................................¬ÄAzÀ ...............................................ªÀgÉUÉ
ªÀiÁUÀð §zÀ¯ÁªÀuÉ ¸ÀܼÀ ...................................................................................................................................
¥Á¸ï ¨ÉÃPÁVgÀĪÀ PÁ¯ÁªÀ¢ü ...........................................................................................................................
±Á¯Á / PÁ¯ÉÃdÄ ¦üà PÀnÖgÀĪÀ gÀ²Ã¢ ¸ÀASÉå .........................................¢£ÁAPÀ .........................................
£Á£ÀÄ §¸ï ¥Á¸ï£ÀÄß zÀÄgÀÄ¥ÀAiÉÆÃUÀ ªÀiÁqÀĪÀÅ¢®è.

vÀAzÉ / vÁ¬Ä / ¥ÉÆõÀPÀgÀ gÀÄdÄ «zÁåyðAiÀÄ ¸À»

¢£ÁAPÀ:
----------------------------------------------------------------------
«zÁå¸ÀA¸ÉܬÄAzÀ PÉÆqÀ¨ÉÃPÁzÀ zÀÈrüÃPÀgÀt ¥ÀvÀæ
ªÉÄð£À £ÀªÀÄÆ£ÉAiÀÄ°è ¤ÃrgÀĪÀ ªÀiÁ»wUÀ¼ÀÄ ¸ÀjAiÀiÁVzÉ. «zÁåyðAiÀÄ ªÉÊAiÀÄQÛPÀ «ªÀgÀUÀ¼ÀÄ «zÁå¸ÀA¸ÉÜAiÀÄ
zÁR¯ÁwAiÀÄ°è £ÀªÀÄÆzÁVgÀĪÀAvÉ EgÀÄvÀÛzÉ JAzÀÄ F ªÀÄÆ®PÀ zÀÈrüÃPÀj¸À¯ÁVzÉ.
«zÁåyðAiÀÄ zÁR¯Áw ¸ÀASÉå: ...........................................................................................................................

¥ÁæZÁAiÀÄðgÀÄ/ªÀÄÄSÉÆåÃ¥ÁzsÁåAiÀÄgÀÄ/ ±Á¯É/PÁ¯ÉÃdÄ/«.« ¤®AiÀÄzÀ ªÉƺÀgÀÄ

ªÀÄÄSÉÆåÃ¥ÁzsÁåAiÀĤAiÀĪÀgÀ gÀÄdÄ ¢£ÁAPÀ:
--------------------------------------------------------------------------------
PÀbÉÃj §¼ÀPÉUÉ ªÀiÁvÀæ
¥Á¸ï / PÁqïð ¸ÀA : .....................................................
¥Á¹£À ZÁ°Û CªÀ¢ü : ......................................ªÀgÉUÉ.....................................
¥ÀæAiÀiÁt zÀgÀ «¢ü¸ÀĪÀ ºÀAvÀUÀ¼ÀÄ : ....................................................................................
ªÀÄÄzÀæt : PÀ.gÁ.gÀ.¸Á ªÀÄÄzÀæuÁ®AiÀÄ, ¨ÉA