Admission Form

Karnataka State Open University

Manasagangothri, Mysore

1. Name : Lakshmipathy EV
2. Father’s Name :Eswarappa V
3. Mother’s Name :Lakshmidevamma
4. Gender : Male
5. Date Of Birth :04/03/1981
6. Nationality :Indian
7. Religion :Hindu
8. Caste :Vokkaliga
9. Category [SC/ST/OBC/GM] :GM
10. Place Of Birth :Yadahalli
11. Mobile Number :9738233131
12. E-Mail ID :pathy12456@yahoo.com
Correspondence & Permanent Address:
● Country :India
● City :Bangalore
● State :Karnataka
● Pin :560033
● Address 1:18/1, 1st Floor, 3rd Cross, Bacahppa Layout, Subbyannapalya
● Address 2:Banaswadi Min Road. MS Nagar Post
13. Are you in Service (Yes/No):No

14. Date of Joining:

15. Office Address: Bengaluru Marriott Hotel Whitefield, No 75 EPIP Area. Bangalore 560066

Course Details:

16. Academic Year:2006/07

17. Course taken : BA Arts

Documents Attached:

● Birth Certificate (10th marks card)(yes/No) : 10th Marks Card

● Degree (Convocation/all semester marks sheets) :KSOU 1st year Marks Card
● Photos :Yes
Qualification Details:

18. Last Exam Passed: 1996

19. University: Karnataka Secondary Education Board

20. Reg. No: 182923

21. Year of Passing: 1996

22. Subjects: Kannada, English, Hindi, Mathematics, Science, Social Studies.

23. Class: First

24. Marks Obtained: 387

25. Total Marks Obtained: 387

26. Percentage: 64%

Declaration:

I clarify that all details furnished are correct to the best of my knowledge and belief, in case of my information
given, being found to be false or any certificate submitted found invalid or forged, I understand that I will loss
my admission and all fees paid will be forfeited, besides being open to other legal action.

Student signature / name as per 10th marks card:

Lakshmipathy EV