UNIVERSITY OF MYSORE

MYSORE, KARNATAKA – 570005

APPLICATION FORM 2014 – 2015

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PROGRAM ENROLLED FOR: ___________________________________________________________________________________________________________________________

STUDENT PERSONAL INFORMATION (PLEASE FILL IN BLOCK LETTERS)

1. NAME _________________________________________________________________________________________________________ (FIRST NAME) (MIDDLE NAME) (LAST NAME)

2. ROLL NO. (For office use only) _______________________________________________________________________________

3. DATE OF BIRTH _________________________________________ 4. STATE ___________________________________ (As Per Marks Card)

5. PLACE OF BIRTH _________________________________________ 6. MOTHER TOUNGE __________________________

7. GENDER _________________ 8. NAME OF FATHER/GUARDIAN/HUSBAND ____________________________________

9. NAME OF MOTHER ___________________________ 10. NATIONALITY ___________________________________

11. POSTAL ADDRESS OF APPLICANT _______________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

12. CONTACT NUMBERS: (1) OFFICE _________________________ (2) MOBILE _____________________________ (With STD Code) (3) RESIDENCE ___________________ (4) E-MAIL ______________________________ 13. CATEGORY __________________________________________ 14. ANNUAL INCOME ___________________________________ 15. WHETHER __________________________________________ 16. ADMISSION CYCLE ___________________________________

Paste Passport

Photo

SL.NO. TYPE OF FEE AMOUNT (`)

1. Application Fee

2. Registration Fee

3. Program Fee

4. Examination Fee

TOTAL

17. Qualifying Examination Passed:

Examination Passed Subject Opted

Board/University Reg. No. & Year of Passing

Marks Obtained

% of Marks

Class Obtained

18. APPLICANTS PROFESSION ________________________________________________________________________________________ 19. WORK EXPERIENCE Overall Work Experience: ________________ Years List all organizations that you have worked with, starting with the current one. (If required, use separate sheet)

Company Address Designation Experience

Job Responsibility From To

20. FEE PAYMENT DETAILS (If payment done online, please share the transaction ID)

FEE PAID D.D. NO. _______________________________ DATED ____________________________________________ BRANCH OF REMITTANCE

____________________________________________________ NAME OF BANK ____________________________________________________

I declare that the information furnished above by me is correct to the best of my knowledge. I also understand that if any of my above statements are found to be untrue, I may be disqualified from the course. I undertake that I shall abide by the rules and regulations of the University.

SPECIMEN SIGNATURE 1. __________________________________ 2. _________________________________________ Place:

Signature of Applicant Date: