Mysore Diocesan Educational Society

St. Philomena’s College

Autonomous College Affiliated toThe University of Mysore
College of Excellence, Reaccredited by NAAC with ‘B++’ Grade
Bannimantap, Mysuru - 570 015

Admission No. Application No. Affix recent

For office use passport
size
colour photograph.

PERSONAL INFORMATION

NAME OF THE APPLICANT

(AS PER SCHOOL RECORD) in BLOCK

GENDER F M COUNTRY: RELIGION: CASTE:

DATE OF BIRTH: DD/MM/YY PLACE OF BIRTH:

Please click the relevant group (enclose the recent caste and income certificates)
GENERAL SC ST CATEGORY 1 CATEGORY 2A 2B 3A 3B PHYSICALLY CHALLENGED

P G APPLICATION FORM
MOTHER'S NAME :

OCCUPATION Mob No :
FATHER'S NAME

OCCUPATION Mob No :

TOTAL ANNUAL INCOME :

AADHAAR NUMBER
APPLICANT MOTHER FATHER

E MAIL ID
APPLICANT

MOTHER

FATHER

GUARDIAN

PERMANENT ADDRESS :
DOOR NO HOUSE NAME

CROSS STREET PIN CODE

VILLAGE TALUK

CITY DISTRICT

STATE POST

LOCAL GUARDIAN'S NAME :

LOCAL ADDRESS :
DOOR NO CROSS STREET

CITY DISTRICT

STATE POST

PIN CODE
 INSTITUTION AND UNIVERSITY LAST ATTENDED

SUBJECTS STUDIED

MARKS OBTAINED IN DEGREE & PERCENTAGE

TOTAL MARKS MARKS SECURED PERCENTAGE

I YEAR I SEM.

II SEM.

II YEAR III SEM.

IIYEAR IV SEM.

III YEAR V SEM.

III YEAR VI SEM.

TOTAL

NUMBER OF ATTEMPTS TAKEN

TO BE FILLED BY THE STUDENTS FROM OTHER STATE (OTHER THAN KARNATAKA)

NAME OF THE STATE

DO YOU BELONG TO ANY RESERVED GROUP? YES NO IF YES: SC ST GR-I OTHERS

TO BE FILLED BY THE STUDENTS FROM FOREIGN COUNTRIES

PASSPORT NUMBER VISA NUMBER

PASSPORT ISSUED AT VISA ISSUED BY

COUNTRY COUNTRY

DATE OF ISSUE DATE OF ISSUE

DATE OF VALIDITY DATE OF VALIDITY

FOR OFFICE USE ONLY

ADMISSION TO CLASS............................................... ADMISSION NO.......................................... ROLL NO.............................

COMBINATION...................................... SECTION............................................. SECOND LANGUAGE.......................................................

AMOUNT RS............................................... DATE.................................................... BK. NO............................... RT. NO...................,,,.......

ANY OTHER FEES..................................... DATE.................................................... BK. NO............................... RT. NO.............................

DETAILS OF ORIGINAL MARKS CARDS AND CERTIFICATES SUBMITTED TO THIS OFFICE AT THE TIME OF ADMISSION

TRANSFER CERTIFICATE NO. DATE OF ISSUE MARKS CARDS

INCOME CERTIFICATE CHARACTER CERTIFICATE