ವಿಶ್ವೇಶ್ವ ರಯ್ಯ ತಾಂತ್ರಿಕ ವಿಶ್ವ ವಿದ್ಯಾಲಯ, ಬೆಳಗಾವಿ

( ವಿತಾವಿ ಅಧಿನಿಯಮ ೧೯೯೪ ರ ಅಡಿಯಲ್ಲಿ ಕರ್ನಾಟಕ ಸರ್ಕಾರದಿಂದ ಸ್ಥಾಪಿತವಾದ ರಾಜ್ಯ ವಿಶ್ವ ವಿದ್ಯಾಲಯ)

Visvesvaraya Technological University, Belagavi

(State University of Government of Karnataka Established as per VTU Act, 1994)

Department of Applied Sciences

Muddenahalli, Chikkaballapur - 562101

APPLICATION FORM FOR ADMISSION TO

M.Sc. in Chemistry Program
PERSONAL DETAILS
Name
(In capital Letters) Recent Passport
Father Name
size photograph
Mother Name
Date of Birth
Gender Male: Female:
Aadhar Card No.
Religion
Caste/ Sub Caste
Category GMR GMK SC ST OBC PH
(Under which seat Special Category (NCC/NSS/Sports/Anglo Indian/Defence/Scouts & Guides)
claimed)
Address for
Correspondence

Mobile Number
Email
EDUCATION DETAILS
SSLC/ 10th
Name of the Institution / Percentage of
Year Max. Marks Marks Obtained
Board and Address Marks

PUC/ 12th /10+2

Name of the Subjects Studies Max. Marks Percentage
Year
Institution / Board Marks Obtained
Languages

Subjects

Total

1
B.Sc.

Name of the Subjects Studies Max. Marks Percentage/

Year CGPA
University Marks Obtained
Subjects Studies

Total
Marks Secured in Chemistry Subject in BSc

Total Marks for Chemistry Subject Marks Secured Percentage

DECLARATION

I hereby certify that all the information furnished above is correct to the best of my knowledge and belief.
Furnishing of any false information will automatically lead to disqualification of my candidature and forfeiture
of all the payments made by me.

Date: Signature of the candidate:

Place: Name of the candidate:

Signature of the Parent/Guardian:

Name of the Parent/Guardian:
List of Enclosures

Particulars Tick if enclosed

SSLC Marks Card
PUC/10+2 Marks Card
BSc Marks Cards
Caste and Income Certificates
Certificates relating to NCC/NSS/Sports/Anglo Indian/Defence/Scouts & Guides
for claiming seat under Special Category
Any other (Please mention)

FOR OFFICE USE

Application No : …………

Candidate Name : ……………………………………………………Percentage of Marks:…….

Category : ……………….

Scrutiny committee Chairperson

2