Annexure-6 Application No: Application No: APPLICATION FORM ÀÆZÀ ÉUÀ¼ÀÄ: 1. ªÀÄä J Áè ÉÃrPÉUÀ½UÉ Àæ ÀPÀÛ zàèrãpàèvà ÀæªÀiÁt ÀvÀæUÀ¼À ÉgÀ¼ÀZÀÄÑ

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1 Annexure-6 Application No: Application No: APPLICATION FORM ÀÆZÀ ÉUÀ¼ÀÄ: 1. ªÀÄä J Áè ÉÃrPÉUÀ½UÉ Àæ ÀPÀÛ zàèrãpàèvà ÀæªÀiÁt ÀvÀæUÀ¼À ÉgÀ¼ÀZÀÄÑ ÀæwUÀ¼À ÀÄß UÀwÛ ÀĪÀÅzÀÄ, 2. J Áè CAPÀtUÀ¼À ÀÄß vàäa ÉÃPÀÄ. ÀA AzsÀ ÀqÀzÀ CAPÀtUÀ½UÉ NA (Not Applicable) JAzÀÄ s Àwð ªÀiÁqÀĪÀÅzÀÄ, C ÀÇtðªÁzÀ CfðAiÀÄ ÀÄß wgà ÀÌj À ÁUÀĪÀÅzÀÄ. 3. F Cfð ÀªÀÄÆ ÉAiÀÄ ÀÄß «±Àé«zÁå AiÀÄzÀ ªÉ ï ÉÊmï APï ( À ªÀÄÆ PÀ që ï ÉÆÃqÀ ªÀiÁr, s Àwð ªÀiÁrzÀ CfðAiÀÄ ÀÄß PÀÄ ÀaªÀgÀÄ, PÀ.gÁ.UÁæ. ÀA.gÁ. «±Àé«zÁå AiÀÄ d ÀgÀ ï PÁjAiÀÄ Àà ÀPÀð ï, UÀzÀUÀ, EªÀjUÉ üã ÁªÀw¹zÀ gà¹ã ªÀÄvÀÄÛ CªÀ±ÀåPÀªÁzÀ zár ÁwUÀ¼À ÀÄß UÀwÛ¹ À è ÀĪÀÅzÀÄ. (ºÉaÑ À ªÀiÁ»wUÁV «±Àé«zÁå AiÀÄzÀ ÀæªÉñÁw C ü ÀÆZÀ É ÉÆÃqÀ ºÀÄzÀÄ.) Instructions: 1. PHOTO COPIES of relevant certificates should be submitted for all your claims. 2. All fields should be filled. Fields not applicable should be written asna.incomplete Application is liable to be rejected. Candidates shall submit separate applications and separate fees for each of the Programme applied for. 3.This application form may be downloaded from the University website and sent to the Registrar, KSRDPR University, Raitha Bhavana, General Cariappa Circle, Gadag , Karnataka, with necessary fees and enclosures (for more details see Admission Notification). AFFIX RECENT PASSPORT SIZE PHOTOGRAPH 1. êÀÅ AiÀiÁªÀ ÁßvÀPÉÆÃvÀÛgÀ ÉÆæÃUÁæªÀiïUÉ ÀæªÉñÀ AiÀÄ ÀÄwÛÃj? To which P.G. Programme do you seek admission? M.B.A M.A. (RDPR) M.A. (PA) M.Sc. (GIS) M.Sc. (FS&T) M.P.H. M.S.W M.A. (DE) M.Com M.Sc. CS (DA) 2. êÀÅ AiÀiÁªÀ ÁßvÀPÉÆÃvÀÛgÀ r ÉÆèêÀiÁ ÉÆæÃUÁæªÀiïUÉ ÀæªÉñÀ AiÀÄ ÀÄwÛÃj? / To which P.G Diploma Programme do you seek Admission? Renewable Energy Co-operative Management Geoinformatics (G.I.S) 3. Cfð ±ÀÄ Ì ÁªÀw¹zÀ «ªÀgÀ/ Application Fees Paid Details: ±ÀÄ Ì/ Fee (in Rupees): ÁåAPï ºÉ ÀgÀÄ ªÀÄvÀÄÛ ±ÁSÉ/ Name of the Bank & Branch: ZÀ ï/r.r. ÀASÉå/D À ÉÊ ï ÁªÀw «ªÀgÀChallan/D.D.Number/Online Payment ÁAPÀ/Date: Details.: 4. C sàåyðaiàä ºÉ ÀgÀÄ (J ï.j ï.j ï.¹ CAPÀ ÀnÖAiÀÄ ègàäªàavé) / Candidate s Name (As per the S.S.L.C Marks Card): vá ÄAiÀÄ ºÉ ÀgÀÄ/PÉ À / Mother s Name/Occupation vàazéaiàä ºÉ ÀgÀÄ/PÉ À / Father s Name/Occupation ÉÇõÀPÀgÀ ºÉ ÀgÀÄ/PÉ À / Guardian s Name/Occupation 5. gá ÖçÃAiÀÄvÉ/Nationality ságàwãaiàä/indian «zéã²/foreigner Page 1 of 5

2 6. AUÀ/Gender : ÀÄgÀĵÀ /Male ¹ÛçÃ/Female AUÀvÀé/Transgender 7. ºÀÄnÖzÀ ÁAPÀ / Date of Birth: 8. eáw / Caste: ªÀUÀð / Category: 9. vàazé/vá ÄAiÀÄ/ ÉÆõÀPÀgÀ ªÁ ðpà ªÀgÀªÀiÁ À Father s / Mother s/guardian s Annual Income: 10. DzsÁgï PÁqïð ÀASÉå/ Aadhaar Card No.: 11. ÀA ÀQð ÀĪÀ «¼Á À/ Address for Correspondence: ÀÆtð ºÉ ÀgÀÄ / Full Name: CAZÉ «¼Á À / Postal Address: à / ªÉÆúÀ Áè Area / Street: CAZÉ/Post: vá ÆPÀ/Tq: f Áè /Dist: gádå/ State: zéã±à/ Country: ÀPÉÆÃqï / Pin Code: ID: ªÉÆà ÉÊ ï ÀA/ Mobile No: 12. êÀÅ PɼÀPÀAqÀ AiÀiÁªÀÅzÁzÀgÀÆ PÉÆÃmÁzÀrAiÀÄ è À æªéã±à EaÒ ÀÄ«gÁ? / Mention whether you claim admission in any of the following quota? QæÃqÁ / Sports ÁA ÀÌöÈwPÀ/ Cultural J ï¹¹/ NCC J ïj ïj ï/ NSS ÉÊ PÀgÀ ªÀÄPÀ̼ÀÄ/ Defence gádåå UÀr sáuàzà C sàåyðuà¼àä / The State Border Area Candidates êÀÅ «PÀ ZÉÃvÀ ÀgÉ?/ Differently Abled / Visually Challenged 13. ÁæAiÉÆÃfvÀ C sàåyðaiàiávzàýgé- ÀA ÉÜAiÀÄ ºÉ ÀgÀÄ ºÁUÀÆ ÀÆPÀÛ zár É ÀvÀæªÀ ÀÄß UÀwÛ¹ (Dgï.r..Dgï / EvÀgÉ E ÁSÉ) CfðUÀ¼À ÀÄß ÀªÀÄÄavÀ ªÀiÁUÀðzÀ ªÀÄÄSÁAvÀgÀ À è ÀĪÀÅzÀÄ./ If you are a Sponsored Candidate mention Organization s name & enclose a copy of the certificate (RDPR / Other Depts.) Application Should be submitted through proper channel. 14. êÀÅ PÀ ÁðlPÀzÀ è K¼ÀÄ ªÀgÀĵÀ «záå sáå À ªÀiÁrgÀÄ«gÁ? / Have you studied 7 years in Karnataka? 15. PÁ²äÃjà ªÀ ¹UÀgÉÃ? / Are you a Kashmiri Migrant? 16. ºÉÊzÀgÁ Ázï PÀ ÁðlPÀzÀ «záåyðaiéäã? / Are you a student of Hyderabad-Karnataka? 17. dªàäää ªÀÄvÀÄÛ PÁ²äÃgÀ «záåyðaiéäã? /Are you a student of Jammu & Kashmir State? jazà 10 Éà vàgàuàwaiàäªàgéué UÁæ«ÄÃt À æzéã±àzà è C sàå¹¹ ÝÃgÁ? / Have you studied in Rural Area upto 10th Std.? jazà 10 Éà vàgàuàwaiàäªàgéué PÀ ÀßqÀ ªÀiÁzsÀåªÀÄzÀ è C sàå¹¹ ÝÃgÁ? / Have you studied in Kannada Medium upto 10th Std.? 20. êÀÅ AiÀiÁªÀÅzÁzÀgÀÆ ÁßvÀPÉÆÃvÀÛgÀ ÀzÀ«CxÀªÁ EAf ÃAiÀÄjAUï, PÀÈ ªÀÄvÀÄÛ EvÀgÀ ªÀÈwÛ ÀgÀ ÀzÀ«ÀqÉ ÝÃgÁ? / Have you passed any Post Graduate Degree or Engineering, Agriculture and Professional Degree? 21. «±Àé«zÁå AiÀÄzÀ è À æªéã±à ÀqÉzÀgÉ «záåyð AiÀÄzÀ Ë s Àå AiÀÄ ÀÄ«gÁ? / Do you need Hostel facility, if you are selected for the P.G Programme in the University 22. véãuàðqéaiàiázà EvÀgÉ ÀjÃPÉëUÀ¼ÀÄ / Other Examination Passed: Page 2 of 5

3 EDUCATIONAL QUALIFICATION 23. CºÀðvÁ ÀzÀ««ªÀgÀUÀ¼ÀÄ / Details of Qualifying Examination: a. ÀzÀ«/ Degree: b. PÁ ÉÃdÄ / ÀܼÀ / College / Place: c. «±Àé«zÁå AiÀÄzÀ ºÉ ÀgÀÄ / Name of the University: d. véãuàðqéaiàiázà ªÀµÀð / Year of passing: ÉÆÃAzÀt ÀASÉå / Register No: e. zàeéð / Class I / II / III: f. MlÄÖ UÀjµÀ CAPÀUÀ¼ÀÄ ( sáµá «µàaiàäuà¼à À»vÀ) / Max. Marks (Including Languages): g. ÀqÉ gàäªà CAPÀUÀ¼ÀÄ ( sáµá «µàaiàäuà¼à À»vÀ) / Marks obtained (Including Languages) h. MlÄÖ ±ÉÃPÀqÁ / Total Percentage i. MlÄÖ LaÑPÀ «µàaiàäuà¼à CAPÀUÀ¼ÀÄ / Max. Marks Optional Subjects j. MlÄÖ ÀqÉ gàäªà CAPÀUÀ¼ÀÄ LaÑPÀ «µàaiàäuà¼àä / Marks obtained in Optional Subjects k. MlÄÖ ±ÉÃPÀqÁ LaÑPÀ «µàaiàäuà¼à / Total Percentage in Optional Subjects 24. EvÀgÉ ªÀiÁ»w / Any other information you would like to furnish: 25. «záåyð ÄAzÀ zàèrüãpàj À àlö MlÄÖ UÀwÛ À ÁzÀ ÀæwUÀ¼ÀÄ / Total Number of enclosures attested by the Candidate: (SSLC/PUC/Degree/Caste/Income/Aadhaar Card/Any other Certificates) C sàåyðaiàä WÉÆõÀuÉ / Declaration by the Candidate Á ÀÄ ªÉÄÃ É w½¹gàäªà J Áè ªÀiÁ»wUÀ¼ÀÄ ÀvÀåªÁVgÀÄvÀÛªÉ JAzÀÄ WÉÆà ÀÄvÉÛÃ É ªÀÄvÀÄÛ AiÀiÁªÀÅzÉà ªÀiÁ»wAiÀÄ ÀÄß CqÀV¹gÀĪÀÅ è. Á ÀÄ và ÀÅöà ªÀiÁ»w ÃrzÀÝ è, PÀ.gÁ.UÁæ.C. ÀA.gÁ. «±Àé«zÁå AiÀĪÀÅ, À Àß «gàäzàþ PÀ æªàä PÉÊUÉƼÀî ºÀÄzÁVgÀÄvÀÛzÉ ºÁUÀÆ À Àß ÀæªÉñÀªÀ ÀÄß ÀºÀ gàzàäý Àr À ºÀÄzÁVzÉ. AiÀÄÄf¹ / ÀæªÉñÀ AiÀĪÀÄUÀ¼À ÀæPÁgÀ Àæw «µàaiàäzà ÀjÃPÉëUÉ ºÁdgÁUÀ Ä PÀ µà 75% ºÁdgÁw PÀqÁØAiÀÄ ªÀÄvÀÄÛ ºÁdgÁwAiÀÄ PÉÆgÀvÉUÉ jaiàiá Äw ÃqÀ Ä AiÀĪÀÄUÀ¼À è CªÀPÁ±À«è J0 ĪÀÅzÀPÉÌ Á ÀÄ zàþ ÁVgÀÄvÉÛà É. Á ÀÄ «±Àé«zÁå AiÀÄzÀ J è AiÀĪÀÄUÀ½UÉ zàþ ÁVgÀÄvÉÛà É. I hereby declare that the above information furnished by me is true. I have not suppressed any information. K.S.R.D.P.R University can initiate action against me, if I have furnished any wrong information and also my admission may be cancelled. I shall hereby undertake to fulfil 75% attendance in each subject (paper) to appear for the examination as per UGC and University Norms and Admission Regulations. I also know that there is no provision in the University rules to condone the shortage of attendance. I shall hereby agree to abide by all the relevant rules and regulations of the University. ÁAPÀ / Date: ÀܼÀ / Place: C sàåyðaiàä À» / Signature of the Applicant Page 3 of 5

4 Application No.: FOR OFFICE USE ONLY Supernumerary Weightage Details Weightage Awardees Name Signature Date Sports Cultural NCC NSS Defence Physically Challenged SL No. 1 Whether photocopy of the SSLC Marks card enclosed 2 Whether photocopy of the PUC Marks card enclosed 3 Qualifying Exam Details to be filled by the applicant and to be verified by the Office Particulars Aggregate % Cognate Subject Cognate Subject % 4 Whether photocopy of the Caste Certificate enclosed If yes, which category you belong to 5 Whether photocopy of the Income Certificate enclosed If yes, parent s / Guardian s annual income 6 Whether photocopy of Aadhaar card enclosed If yes, Aadhaar Card No : 7 Whether registered for scholarship in Social Welfare Department? (for SC/ST applicants only) 8 Whether applied for scholarship in Backward Classes Welfare Department in the previous year? 9 Whether the candidate has applied for any supernumerary quota (SL. 16 to 19) If yes, mention Registration No : If yes, mention Registration No : Signature of the Verifying Official Signature of the Applicant Signature of Programme Admission Co-ordinator Admission Committee Co-ordinator REGISTRAR Page 4 of 5

5 UNIVERSITY COPY 1. Candidate s Name : Application No. :.. 3. PG Programme :.. 4. Category :.. 5. Date of Submission :.. 6. Application Fee Paid Challan / DD No. Rs. Collecting Official s Name & Signature.. CUT HERE CANDIDATE COPY 1. Candidate s Name : Application No. :.. 3. PG Programme :.. 4. Category :.. 5. Date of Submission :. 6. Application Fee paid Challan / DD No. Rs. Collecting Official s Name & Signature Page 5 of 5