KARNATAKA STATE OPEN UNIVERSITYManasagangotrl, Mysore - 570006, Kamataka, India

&SANDIP FOUNDATION, MUMBAI • 400 080

5230

A1lixa _portaile photographduly oigned by thecandidate at thetop and atte.ledby a Ga~ettedOfficer at thebottomEnrolment No. (For office use only)

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4. Date of Birth: 5. Sex :(v) 6.~g;;J~ ~ 7. Mother tongue:

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City or Town :

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11.Course Applied For: 1 1 Stream: 1 1 Se~ester: 1 1

12.DDNumber: DD Date: Amount:

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ITIIJlO.Study Centre Code:

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Examination Passed Month & Year Subject Percentage Name of theof Passing of Marks Board/University

• Check List :

D Date of Birth Certificate/Proof .D X th Marksheet D X th Passing Certificate

DXII th Marksheet (PCM) DXII th Passing Certificate

DDiploma Final sem./year Mar~sheet DDiploma Passing /Provisional Certtificate.

D I.T.I./NCVf./MCVC Marksheet & Certificate

D Any Other Supporting Document 1================================================

To,The Dean AcademicsKarnataka State Open UniversityManasagangotri, MysoreKarnataka - 06

This is to declare that, 1. Son /Daughterof have taken admission in programme in (January/July) 200 __ in_____ Stream under Karnataka State Open University. And I assure that all the documents enclosed related to myqualification regarding the admission are genuine and au thentic .

•I say and submit that I am under going programme of Karnataka State Open University, Mysore to gainand enhance my knowledge and Academic value and Imay not get advantage in teachings job.

I say and submit that to gain and enhance my knowledge and Academic value I want to Join _programme / academic course of Karnataka State Open University, Mysore and further advancement of my professionalcareer.

In the event of suppression or distortion of any fact like educational qualification, documents related to nationality andstudy period etc. made in my application form, I understand that my admission is liable to be cancelled.

I am eligible for the examination as per the rules and regulations of the university. I shall be responsible for theconsequences if the information filled by me is found incorrect. If I am found ineligible for admission to a class, at any stagemy application will be rejected even ifmy result has been finally declared and consequently such result also would be void.

I further say and submit that even ifI do not get any advantage of said course after its completion, I hereby\mdertake not tohold the above University, its Institute or any other person responsible in any manner for getting no benefit of said course. Isay and declare that above course advanced by said University is only'for enhancement of my knowledge and nothing moreand with that clear understanding Ijoined the said course at my own risk and cost. I further say that I have gone throughthe prospectus of said University and I am fully satisfied with contents ofthe same.

Signature of the Candidate

Enrollment No./Roll No. _

This Is to certify that Mr.f.Ms./Mrs, ~ Son / Daughter /Wife is a student registered from our Study Centre. The photo pasted on thisform depicts his /her current appearance correctly. I have personally checked all the documents enclosed herewith. Iattest that all the entries are correct. I, as well as the candidate, Know that if his/her result is finally not declared due toineligibility, I and the students shall bear fully responsible for rejection and not the University.