母獟尷斂¦Ai斂贏z糠索w Cf I PUC Admission Application Form 2014-15

66
Cfð ¸ÀASÉå/Application No:
PÀ£ÁðlPÀ ¸ÀPÁðgÀ/ Government of Karnataka
¥ÀzÀ« ¥ÀÆªÀð ²PÀët E¯ÁSÉ / Department of Pre-University Education
¥Àæxª
À ÀÄ ¦AiÀÄÄ¹ zÁR¯Áw Cfð/ I PUC Admission Application Form 2014-15
EwÛÃa£À ¨sÁªÀ avÀæª£
À ÀÄß
CAn¹
PÀbÉÃj G¥ÀAiÉÆÃUÀPÁÌV ªÀi ÁvÀæ / For Office use only
1. zÁR¯Áw ¸ÀASÉå/ Admission No
2.
3.
4.
5.
Affix recent
pass port size
photograph
¨sÁµÉUÀ¼ÀÄ –ªÀ-¸ÀAAiÉÆÃd£É/Languages –cum- combination.
ªÀi ÁzsÀåªÀÄ/ Medium PÀ£ÀßqÀ/Kannada
EAVèÃµï/English
«¨sÁUÀ/ Section
«ÄÃ¸À¯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
2.b) °AUÀ/Gender :
ºÀÄqÀÄV/Female or ºÀÄqÀÄUÀ /Male
3.a) zsÀªÀÄð/Religion.
3.b). eÁw / Caste:
4. «zÁåyðAiÀÄ
«¼Á¸À
SÁAiÀÄA «¼Á¸À/Permanent Address.
MONTH
YEAR.
3.c). G¥ÀeÁw / Sub Caste:
ªÀåªÀºÁjPÀ «¼Á¸À /Correspondence Address
Candidate’s Address
Tel No/Mobile No:
5. «zÁåyðAiÀÄ vÁ¬Ä ªÀÄvÀÄÛ vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ:
Name of the Parents :
6. ¥ÉÆÃµÀPÀgÀ ºÉ¸ÀgÀÄ ªÀÄvÀÄÛ «¼Á¸À :
vÁ¬Ä/ Mother
vÀAzÉ/ Father
Name of the Gaurdian with Address :
7. ¥ÉÆÃµÀPÀgÀ ªÁ¶ðPÀ DzÁAiÀÄ
:
DzÁAiÀÄ ¥ÀæªiÀ Át ¥ÀvÀæ ®UÀwÛ¹zÉAiÀiÁ? yes
Parents Annual Income
:
Is Income Certificate enclosed
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/vÀvÀìªiÀ Á£À ¥ÀjÃPÁë «ªÀgÀ
Particulars of SSLC /equivalent examination passed.
£ÉÆÃAzÀtÂ ¸ÀASÉå /Reg No:
ªÀµÀð/Year:
wAUÀ¼ÀÄ/month
__ ____ ____ ___ ____ ____ ____ ________ cut here ____ ___ ____ ____ ____ ____ ___
PÀÄªÀiÁgÀ/ PÀÄªÀiÁj ______________________________________ gÀªÀjAzÀ _____________________
¸ÀAAiÉÆÃd£ÉUÉ ¥ÀæxÀªÀÄ / ¢éwÃAiÀÄ ¦AiÀÄÄ¹UÉ ¥ÀæªÉÃ±À CfðAiÀÄ£ÀÄß ¥ÀqÉAiÀÄ¯ÁVzÉ.
¸ÀÜ¼À/Place:
¢£ÁAPÀ/ Date:
Cfð ¹éÃPÀj¹zÀªÀgÀ ¸À»
67
10
C¨sÁå¸À ªÀiÁrzÀ «µÀAiÀÄUÀ¼ÀÄ/ Subjects studied
¥ÀqÉzÀ CAPÀUÀ¼ÀÄ Marks obtained
ªÀiÁzsÀåªÀÄ/Medium
1. ¥ÀæxÀªÀÄ ¨sÁµÉ/ 1st Language __________________________________¥sÀ°vÁA±À/ Result
2. ¢éwÃAiÀÄ ¨sÁµÉ/ 2nd Language ______________________________________
rd
3. vÀÈ wÃAiÀÄ ¨sÁµÉ/3 Language __________________________________
4. «eÁÕ£/À Science
_________________________________
5 .UÀtÂvÀ / Mathematics
±ÉÃPÀqÀª ÁgÀÄ CAPÀUÀ¼ÀÄ:
Percentage of Marks
6. ¸ÀªÀiÁd«eÁÕ£À/Social Science__________________________________
¥ÀqÉzÀ MlÄÖ CAPÀUÀ¼ÀÄ/ Total Marks obtained
11 .QæÃqÉ/ ¥ÀoÉå ÃvÀgÀ ZÀlÄªÀnPÉUÀ¼À°è ¨sÁUÀª»
À ¹zÀÝ «ªÀgÀUÀ¼ÀÄ:
Participation in Sports/ Extra Curricular activities:
12. ¦AiÀÄÄ¹AiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀ§AiÀÄ¸ÀÄªÀ ¨sÁµÉUÀ¼ÀÄ
ªÀÄvÀÄÛ ¸ÀAAiÉÆÃd£É
subjects
Languages and Combination offered
to study in the PU Course
¨sÁUÀ- I/Part-I
¨sÁµÁ «µÀAiÀÄUÀ¼ÀÄ
1.
2.
¨sÁUÀ- II /Part-II
LaÑPÀ «µÀAiÀÄUÀ¼ÀÄ/Optional
1
2.
3.
4.
13. ¦AiÀÄÄ¹AiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀÄªÀ ªÀiÁzsÀåªÀÄ
Medium of instruction in PU Course.
PÀ£ÀßqÀ
EAVèÃµï
Kannada
English
14.«zÁåyðAiÀÄ ªÀÄvÀÄÛ ¥ÉÆÃµÀPÀgÀ ªÀÄÄZÀÑ½PÉ / 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 ¤AiÀÄªÀÄUÀ½UÉ §zÀÞ£ÁVgÀÄvÉÛÃ£ÉAzÀÄ
M¦àgÀÄvÉÛÃ£É.
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 £Àqz
É ÄÀ PÉÆ¼ÀÄîvÉÛÃ£ÉAzÀÄ, MAzÀÄ ªÉÃ¼É C²¹Û¤AzÀ
ªÀwð¹zÀÝ°/è PÁ¯ÉÃf£À D¹Û¥Á¹ÛUÉ ºÁ¤ªÀiÁrzÀ°è CzÀjAzÁzÀ £ÀµÖª
À £
À ÀÄß £Á£ÉÃ vÀÄA©PÉÆqÀÄªÀÅzÁV M¦àgÄÀ vÉÛÃ£É.
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 w½AiÀÄÄvÉÛÃ£ÉAzÀÄ, «zÁåyðAiÀÄ
C²¹Û¤AzÀ DzÀ £ÀµÖª
À £
À ÀÄß vÀÄA© PÉÆqÀÄªÀÅzÀPÉÌ §zÀÝ£ÁVgÀÄvÉÛÃ£ÉAzÀÄ M¦àgÀÄvÉÛÃ£É.
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.
¸ÀÜ¼À /Place:
¢£Á0PÀ/ Date:
vÁ¬Ä/vÀAzÉ/¥ÉÆÃµÀPÀgÀ ¸À»/
«zÁåy9AiÀÄ ¸À»/
Signature of the Student
Signature of the Mother/Father/Gaurdian,
PÀbÉÃj G¥ÀAiÉÆÃUÀPÉÌ
zÁR¯Áw ¸ÀASÉå ____________ ±ÀÄ®Ì gÀÆ ____________gÀ¹Ãw
¸ÀASÉå___________¢£ÁAPÀ_______ «ÄÃ¸À¯Áw ªÀUÀð/ Reservation category
¥ÀzÀ« ¥ÀÆªÀð ²PÀët E¯ÁSÉAiÀÄ C£ÀÄªÉÆÃzÀ£É ºÁUÀÆ ¤AiÀÄªÀÄUÀ½UÉ §zÀÞªÁV, ºÁUÀÆ CUÀvÀå EgÀÄªÀ J¯Áè ªÀÄÆ®
15.
zÁR¯ÉUÀ¼À£ÀÄß ¸À°¸
è ÀÄªÀ µÀgÀwÛ£ÉÆA¢UÉ vÁvÁÌ°PÀÀªÁV zÁR¯Áw ªÀi ÁrPÉÆ¼Àî¯ÁVzÉ.
¢£ÁAPÀ:
zÁR¯Áw ¸À«ÄwAiÀÄ ¸ÀzÀ¸ÀågÀ ¸À»
¥ÁæA±ÀÄ¥Á®gÀÄ ¸À»
¸ÀÆZÀ£ÉUÀ¼ÀÄ/Instructions
1 .zÁR¯ÁwAiÀÄÄ vÁvÁÌ°PÀªÁVzÀÄ Ý, E¯ÁSÉAiÀÄ C£ÀÄªÉÆÃzÀ£ÉUÉ M¼À¥n
À ÖgÀÄvÀÛz.É
Admission to PUC is provisional & is subjected to Department approval.
2. CAPÀ¥ÀnÖ, ªÀÄÆ® ªÀUÁðªÀuÉ¥v
À Àæ, 10£ÉÃ vÀgÀUÀw ¥ÀjÃPÉë ¥ÀæªÉÃ±À ¥ÀvÀæzÀ £ÀPÀ®Ä ¥Àæw eÁw ªÀÄvÀÄÛ DzÁAiÀÄ ¥ÀæªiÀ Át¥ÀvÀæ ºÁUÀÄ EvÀgÉ zÁR¯ÉUÀ¼À
zÀÈrüÃPÀj¹zÀ ¥ÀæwUÀ¼À£ÀÄß PÀqÁØAiÀÄ ªÁV CfðeÉÆvÉ ¸À°¸
è À¨ÉÃPÀÄ. ªÀÄÆ® ¥ÀæwUÀ¼À£ÀÄß zÁR¯Áw ¸ÀªÀÄ AiÀÄzÀ°è PÀqÁØAiÀÄªÁV ¥Àj²Ã®£ÉUÉ gÀÄ¥Àr¸À¨ÃÉ PÀÄ.
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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