Cfð ¸ÀASÉå/Application No:

PÀ£ÁðlPÀ ¸ÀPÁðgÀ/ Government of Karnataka

¥ÀzÀ« ¥ÀƪÀð ²PÀët E¯ÁSÉ / Department of Pre-University Education
¥ÀæxÀªÄÀ /¢éwÃAiÀÄ ¦AiÀÄĹ zÁR¯Áw Cfð/ I /IIPUC Admission Application Form 2017-18
PÀbÉÃj G¥ÀAiÉÆÃUÀPÁÌV ªÀi ÁvÀæ / For Office use only EwÛÃa£À ¨sÁªÀ avÀ檣
À ÀÄß
CAn¹
1. zÁR¯Áw ¸ÀASÉå/ Admission No
Affix recent
2. ¨sÁµÉUÀ¼ÀÄ –ªÀ-¸ÀAAiÉÆÃd£É/Languages –cum- combination. pass port size
3. ªÀi ÁzsÀåªÀÄ/ Medium PÀ£ÀßqÀ/Kannada EAVèõï/English photograph
4. «¨sÁUÀ/ Section
5. «ÄøÀ¯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 MONTH YEAR.

2.b) °AUÀ/Gender : ¨Á®Q/Girl or ¨Á®PÀ/Boy

2. c) ºÀÄnÖzÀ ¸ÀܼÀ gÁdå f¯Éè vÁ®ÆèPÀÄ
place of birth State District Taluk
3.a)Nationality/gÁ¶ÖçÃAiÀivÉ b)zsÀªÀÄð/Religion. c). eÁw/Caste: 3.)G¥ÀeÁw / Subcaste:
4. «zÁåyðAiÀÄ SÁAiÀÄA «¼Á¸À/Permanent Address. ¸ÀܽAiÀÄÀ«¼Á¸À/Local Address
«¼Á¸À
Student’s Address
Tel No/Mobile No: Aadhar No:
5. «zÁåyðAiÀÄ vÀAzÉ ªÀÄvÀÄÛ vÁ¬Ä/¥Á®PÀgÀ ºÉ¸ÀgÀÄ: vÁ¬Ä/ Mother
Name of the Parents/Guardian : vÀAzÉ/ Father
6. ¥ÉÆõÀPÀgÀ/¥Á®PÀgÀ «¼Á¸À:
Address of the Parents/Gaurdian :

7. ¥ÉÆõÀPÀgÀ/¥Á®PÀgÀ ªÁ¶ðPÀ DzÁAiÀÄ : DzÁAiÀÄ ¥ÀæªiÀ Át¥ÀvÀæ ®UÀwÛ¹zÉAiÀiÁ?ºËzÀÄ/E®è

Parents /GuardianAnnual Income : Is Income Certificate enclosed yes/ 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 £ÉÆÃAzÀt ¸ÀASÉå /Reg No:

Particulars of SSLC /equivalent examination passed. ªÀµÀð/Year: wAUÀ¼ÀÄ/month
10. «PÀ®ZÉÃvÀ£À/CAzÀvÀé/§Ä¢ÝªÀiÁAzÀå ºÉÆA¢Ýzg
À É zÁR¯ÉAiÀÄ£ÀÄß ®UÀwÛ¹zÉAiÉÄà ºËzÀÄ/E®è
If whether Physically challenged/Blind/Mentally chanllenged Documents Enclosed Yes/NO

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¢£ÁAPÀ/ Date: Cfð ¹éÃPÀj¹zÀªÀgÀ ¸À»
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11 C¨sÁå¸À ªÀiÁrzÀ «µÀAiÀÄUÀ¼ÀÄ Subjects ¥ÀqÉzÀ CAPÀUÀ¼ÀÄ Marks obtained ªÀiÁzsÀåª ÀÄ/Medium
st
1. ¥ÀæxÀªÀÄ ¨sÁµÉ/ 1 Language ¥sÀ°vÁA±À/ Result
nd
2. ¢éwÃAiÀÄ ¨sÁµÉ/ 2 Language
rd
3. vÀÈ wÃAiÀÄ ¨sÁµÉ/3 Language
4. «eÁÕ£/À Science À ÁgÀÄCAPÀUÀ¼ÀÄ:
±ÉÃPÀqª

5. UÀtÂvÀ / Mathematics Percentage of Marks

6. ¸ÀªÀiÁd«eÁÕ£À/Social Science
¥ÀqÉzÀ MlÄÖ CAPÀUÀ¼ÀÄ/ Total Marks obtained
12 .QæÃqÉ/ ¥ÀoÉåÃvÀgÀ ZÀlĪÀnPÉUÀ¼À°è ¨sÁUÀª»
À ¹zÀÝ «ªÀgÀUÀ¼ÀÄ:
Participation in Sports/ Extra Curricular activities:
13. ¦AiÀÄĹAiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀ§AiÀĸÀĪÀ ¨sÁµÉUÀ¼ÀÄ ¨sÁUÀ- I/Part-I ¨sÁUÀ- II /Part-II
ªÀÄvÀÄÛ ¸ÀAAiÉÆÃd£É ¨sÁµÁ «µÀAiÀÄUÀ¼ÀÄ LaÑPÀ «µÀAiÀÄUÀ¼ÀÄ/Optional
subjects
Languages and Combination offered 1. 1
to study in the PU Course 2. 2.
3.
4.
14. ¦AiÀÄĹAiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁqÀĪÀ ªÀiÁzsÀåªÀÄ PÀ£ÀßqÀ EAVèõï
Medium of instruction in PU Course. Kannada English
15 .«zÁåyðAiÀÄ ªÀÄvÀÄÛ ¥ÉÆõÀPÀgÀ ªÀÄÄZÀѽPÉ / Student’s and Parent’s/Gaurdian’s undertaking.
1. £À£Àß PÁ¯ÉÃf£À ªÁå¸ÀAUÁªÀ¢üAiÀÄ°è E¯ÁSÉAiÀÄ J¯Áè DqÀ½vÀ/±ÉåPÀëtP À/¥ÀjÃPÁë ¤AiÀĪÀÄUÀ½UÉ §zÀÞ£ÁVgÀÄvÉÛãÉAzÀÄ M¦àgÀÄvÉÛãÉ.
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 £ÀqzÉ ÄÀ PÉƼÀÄîvÉÛãÉAzÀÄ, MAzÀÄ ªÉÃ¼É C²¹Û¤AzÀ
ªÀwð¹zÀÝ°/è PÁ¯ÉÃf£À D¹Û¥Á¹ÛUÉ ºÁ¤ªÀiÁrzÀ°è CzÀjAzÁzÀ £ÀµÖª À £À ÀÄß £Á£Éà vÀÄA©PÉÆqÀĪÀÅzÁV M¦àgÄÀ vÉÛãÉ.
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 w½AiÀÄÄvÉÛãÉAzÀÄ, «zÁåyðAiÀÄ
C²¹Û¤AzÀ DzÀ £ÀµÖª À £À ÀÄß vÀÄA© PÉÆqÀĪÀÅzÀPÉÌ §zÀÝ£ÁVgÀÄvÉÛãÉAzÀÄ M¦àgÀÄvÉÛãÉ.
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.

¸ÀܼÀ /Place: «zÁåy9AiÀÄ ¸À»/ vÁ¬Ä/vÀAzÉ/¥ÉÆõÀPÀgÀ ¸À»/

¢£Á0PÀ/ Date: Signature of the Student Signature of the Mother/Father/Gaurdian,

16. PÀbÉÃj G¥ÀAiÉÆÃUÀPÉÌ

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«ÄøÀ¯Áw ªÀUÀð/ Reservation category
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¸ÀÆZÀ£ÉUÀ¼ÀÄ/Instructions
1 .zÁR¯ÁwAiÀÄÄ vÁvÁÌ°PÀªÁVzÀÄ Ý, E¯ÁSÉAiÀÄ C£ÀĪÉÆÃzÀ£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£Éà vÀgÀUÀw ¥ÀjÃPÉë ¥ÀæªÉñÀ ¥ÀvÀæzÀ £ÀPÀ®Ä ¥Àæw eÁw ªÀÄvÀÄÛ DzÁAiÀÄ ¥ÀæªiÀ Át¥ÀvÀæ ºÁUÀÄ EvÀgÉ zÁR¯ÉUÀ¼À
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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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 GOVERNMENT OF KARNATAKA
DEPARTMENT OF PRE-UNIVERSITY EDUCATION

APPLICATION FOR LANGUAGE EXEMPTION IN PART-1 for PUC Students (2017-18)

SL. PARTICULARS INFORMATION TO BE PROVIDED
NO
1 Name of the Student
(in block letters)
2 Name of the Mother
(in block letters)
3 Name of the Father
(in block letters)
4 Name and address of the College

5 SSLC/10th standard Register number a)

and year of passing.(Enclose Xerox
attested Markscard) b)
6 Reasons for claiming exemption
(Details with class, claiming exemption in
language,Combination and Medium )

7 Documents to be enclosed:

a) Attested copy of the marks card. a) Attested/Not attested

b)Attested copy of Exemption order issued for b) Attested/Not attested
th
language exemption in SSLC/10 standard. c) Attested/Not attested
c) Attested copy of the Medical Certificate

8 Residential Address of the Student

(in block letters)

place:
Date: Signature of the Student.

The above student may be given exemption from studying ……………………………………….

Language in 1st and 2nd PUC.

Place:
Date:
 GOVERNMENT OF KARNATAKA
DEPARTMENT OF PRE-UNIVERSITY EDUCATION

APPLICATION FOR ISSUE OF MIGRATION CERTIFICATE (2017-18)

Name of the student
01
(in block letters)
Father ‘s name
02
(in block letters)
Name of the institution last
03
Attended

Examination passed with

04 Reg. No. and year of passing
and combination studied

Prescribed fee of Rs 360-00 (Three hundred and Challan No.

Sixty only) has to be remitted to Head of Account -
Dated
“0202 Education Sports, arts & culture
01 General education, 102 secondary Education, 1 Remitted at
05
Tution and other Fees
07 Examinaion fees of junior colleges
Is enclosed.
(HOA: 0202-01- 102-1-06)
(Original challan to be enclosed)

06 Reason for Migration

Whether attested copies of following

documents enclosed:

07 1. Marks card/Marks statement

2. Transfer certificate/no due certificate
issued by the Head of the Institution

Address of the student

08
(in block letters)

Place :
Date :
SIGNATURE OF THE STUDENT
 GOVERNMENT OF KARNATAKA

DIRECTORATE OF PRE-UNIVERSITY EDUCATION

APPLICATION FOR THE ISSUE OF ELIGIBILITY CERTIFICATE (2017-18)
(Read the instructions before filling in)
Name of the student with Previous college address.
01
(in block letters)
Father’s name
02
(in block letters)
03 Nationality

Residential address:
04
a) In your Country (applicable to foreign students)

b) In India

Qualifying examination
a) Name of the Examination with Register No
05
(Name of the examining body/University
b) Year of schooling

Whether seeking admission to

06 I YEAR PUC / II YEAR PUC
(Tick whichever applicable)
07 Steam of course of study (tick mark) SCIENCE / COMMERCE / ARTS
Names of 3 Colleges in order 1)

08 of preference where candidate 2)

desire to seek admission 3)

09 Fees remitted Challan No ............... Date.......................

Attested testimonials and other required documents to be enclosed

with this application:
i) Statement of marks certificate of the qualifying examination
passed.
10
ii) Transfer Certificate,
iii) Bonafide certificate
iv) Migration Certificate issued by the head of the institution
where the student attended previously. From university / board.

11 Any other information the student wishes to furnish

Certified that the information furnished above is true and correct to the best of my knowledge and belief.

Place :
Date :
SIGNATURE OF THE STUDENT
 INSTRUCTIONS (ELIGIBILITY CERTIFICATE)

The rate of eligibility fee shall be is Rs 3600-00 per certificate in case of foreign and
NRI’s and Rs 600-00 per certificate to the students who qualify an equivalent examination
conducted by a Board / University or autonomous body within India.

1. The mode of payment of fee shall be through challan. Head of A/c to remit the
fees are as follows.

0202 - Education arts sports and culture,

01 - General education
102 - Secondary Education
1 - Tuition and other fees
06 - Tution fees of Junior colleges and other fees
Code No 0202-01-102-1-06

2. The original certificate of qualification and other requisite documents along with one
photocopy of each shall invariably to be enclosed with the application, the original shall be
returned while issuing provisional eligibility certificate.

3. The information called for in the application should be complete and correct.
Incomplete applications are liable for rejection.

4. The candidate seeking provisional eligibility certificates for admission to II year PUC
will have to enclose a copy of tenth grade examination in addition to eleventh grade examination.

5. Any other information pertaining to qualifying examination, bonafide certificate and

migration certificate and rules thereof would essentially required of a candidate, shall have to
furnished at once, when called upon before issuing the provisional eligibility certificate.

****
 ELIGIBILITY CERTIFICATE FOR PARTICIPATING
Fix recent passport size
photograph
IN (Participants Name and
SPORTS / CULTURAL EVENTS Date of photograph
must be printed on
photo

1 Name of the Participant

(In Block Letters)
2 Name of the Mother
3 Name of the Father
4 Residential Address with
Phone No & Mobile No

5 Name & Address of the Name :

Institution Code :
Phone No.__________________
6 Student No. and Year of
Admission
7 SSLC Register Number
8 Date of Birth
(As per SSLC Marks Card)
9 Age in completed Year as on
31st December 2017
10 Class in which studying I PUC II PUC
11 Personal Identification 1.
2.
12 Next to Kin with full address
and Mobile No
13 Blood Group

Note: Participant’s Name & date of the photograph must be printed on the passport photograph.

Certificates :
a. certified that I, the undersigned has personally verified the records and found that the
information given above are correct.
b. Certified that the participant is a bonafide Pre-University student of this institution for the
Academic Year _____________
3. Certified that the attested Xerox copy of the SSLC Marks card is enclosed.

Signature of the Signature of the Signature of the

Participant Secretary / P.E. Teacher Principal
Name in Block Letters with Name (in Block Letters) with College Seal
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 PROFORMA - A
GOVERNMENT OF KARNATAKA
DEPARTMENT OF PRE-UNIVERSITY EDUCATION
Academic, Recognition, Particulars of the College
(With Financial Statement)

1. Name of the Principal:

2. Principal’s Phone and mobile nos.
3. Email ID

4. Name of the College College Code NO.

5. Type of College : Govt / Aided / Un-Aided

(Please tick the appropriate type)

6. Subject permitted to teach :

Language Subjects (Indicate Subject Code Numbers)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Permitted Combinations: (Enclose the order copy)

Subjects in the combination Combination wise Student Strength

(Indicate Code Numbers) Boys Girls Total
1
C
O 2
M 3
B
4
I
N 5
A
6
T
I 7
O
8
N
9

7. Particulars of the students admitted to First PUC

SI. Combination wise Student Strength
Category
NO Boys Girls Total
1 General category (Merit)
2 S.C.
3 S.T.
4 Category – 1
5 Category - 2A
6 Category - 2B
7 Category - 3A
8 Category - 3B
9 Physically Disabled
8. Sections Permitted Arts/Science/Commerce

9. Admission Details

Details of I PUC II PUC TOTAL

Admissions for the Year 2016 – 2017
Students Exempted from paying Fees
10. Collection of Fees :

SL. No. of
Types of Fees I PUC II PUC TOTAL
NO students
1 Tuition Fees
2 Admission Fees
3 Registration Fees
4 Late Admission Fees
5 Special Late Admission Fees
6 Eligibility Fees
7 Change of Col/Combination Fee
8 Private Study Fees
9 Other (Specify Details)

Total Fees Remitted Rs ..................... ....................... (Words........................................................................

......................................................................................... vide Challan.No/s..........................................
Date..................................

11. Indicate balance of non-govt. funds : as on 21.07.2016.

Sl.No. Particulars Amt. Sl.No. Particulars Amt.

1 Sports 8 SWF
2 R.R. 9 TBF
3 Cultural Activities 10 SSF
4 Class Exam. (I & II) 11 Lab.
5 Toilet Maintenance 12 Flag
6 Elec. & Water 13 S.B.C.
7 Others, if any 14 Others, if any

SIGNATURE OF THE PRINCIPAL WITH OFFICE SEAL

List of enclosures to be sent by September- 9-2017 :

Set -1( Academic Section)
· Proforma . A
· Original Challans
· Uptodate Renewal of Recognition
copy
· Fee Structure Copy.
· Selection list as Roasterwise
Set -2(Examination Section)
· List of Students in Annexure – 2 with enclosures
· List of Students opted for Private Study with
applications
· Change of College List with applications
· Change of combination list with applications

The above two sets of Documents should be submitted at DDPUE’s office intime for approval of
students .

· Special Note: List of Students in Annexure – 1 (To be compulsorily maintained in the College
office )