ROLL II....D.... CARD NO....
KARNATAKA STATE 8 OPEN UNIVERSITY
MUKTHAGANGOTRI, MYSORE 570 006
APPLICATION FORM FOR REGISTRATION
First Year Second Year M....Ed Examination ........................................................................................................................................................ 20
(Distance Education Scheme)
Note i) Please read carefully the instructions given overleaf before filling up the application, as well as instruction in the prospectus....
ii) Strike off whichever is not applicable....
Affix
Stamp Size
Photo here
Mobile No ........................ ........................................................................................................................................................................ ............ .... Landline No ........................................................................................ ........ .................................................................................................... .... EmailiD ............................................................................ ........................................................................................ ........................................................ ....
Name of the Examination Centre
.... Name of the Candidate (In block letters)
(as in qualifying examination records)
2.... Permanent Postal Address with pin code
(in block letters)
Pin r....nnp
3.... SubjectsPapers for which to appear (compulsorily indicate Reg.... No...., Year and Month of passing the previous examinations, if any) ('P' for assed, '/for appearing)
First Year M....Ed Second Year M....Ed
NP Subjects
Year&
NP Subjects
Month
Year&
Month
Karnataka Stlte Open University, Mysore
Name of the Bank &
Place of Remittance ....................
Name of the Course M....Ed ........................
Roll No
KSOU500EXAMINATION FUND
SBM5403542028 SBI306997538
SBM, Mukthagangoui, Mysore........,
SBI........ New Sayyaji Rao Road, Mysore0
Name and Address of the Student c
4....CATEGORY Cat Cat Cat Cat Cat G (mark(_,; ) to which you belong
G....M....
50 Examination Fee
Penal Fee
Chanze of
7.... Did you attend
5.... Sex 6.... Medium
I.... Contact Programme II.... Submitted the .... Appeared for Test
Assignment
MaleFemale EnglishKannada YesD NLJ Yes once YesD NoD Date Signature of the Remitler
8.... Year In which the candidate For the use or the Bank
completed the course
I Amount Paid Date9.... Details of fees paid
Name of the Bank
The Amount of Rupees (in words) ........................................................................................................ ........
has been received I
Challan o....
Date &
Bank Seal
Signature of the Officer
receiving the money
UNIVERSITY COPY
Not to be seperated from the Form
Karnataka State Open University, Mysore Karnataka State Open University, Mysore; Karnataka State Open University, Mysore
Name of the Bank & Name of the Bank & Name of the Bank &
; l....Ed.... heem ·.... heem ·........·....·....·........_ ............................................ ........
Roll NoRoll No Roll No ................_ _____________ __,
KSOUEXAMlNATIONFUNDKSOU500EXAMlNATIONFUND ....................JKSOUEXAMINATIONFUND
SBM 5403542028 SBI3 06997538SBM54035420 28 SBI3 t07)j8 SBM54035420 28 SBI3 06997538
SBM, Mukthagangotri , Mysore · 06 SBI, Mukthagangotri, Mysore .... 06 f'""' SBM, Mukthaggotn, Mysore · 08 ...................._'
SBI, New Sayyaji Rao Road, Mysore0 SBI, New Sayyaji Rao Road.... Mysore0 VSB[, New Sayy&JI Rao Road, Mysorc0 s........
Nt Md AdWm of Srudmt Q Nt Md Add" oftht Srudmt N MdAdW= oftht Studrnt (; C
G A& r;,C ........ .... 50 Examination Fe....h....;;_ ISO! Examination Fee 50 Examanatton h
Penal Fee ....;; Penal Fee , Penal Fee ........ &....fo'Ve
Chanee or Fee Chanceft eeCbanze "Vo e Fee
Amount (in words) Ruees ............................................................................................................................................................ Amount (in w upees ............................................................................................................................................................ Amount (is) ees .................................................................................................................................................... ........

Date Signature of the RemitterDat Signature of the RemitterDate Stanature of the Remtlter
For the use of the Bank For the use of the BankFor the use of tbe Bank
The Amount of Rupees (in words)................................................................................................................The Amount of Rupees (in The Amount of Rupees (in
has been receivedI words)....................................................................................................................................................................................................words) ............................................................................................................................................................................................ ....
Challan No....has been receh·ed has been received I
Date & Sienature of the OfficerChallan No....Challan No....
Bank Seal .... .... ........ receivin& the money Date & Sienature of the Officer Date & Siena of the Officer
To be retamed wath the receavanc bankBank Seal receiin& the moneyBank Sui recevane tbe money
Receivin& Bank should send this copy to the Finance Student copy to be rtaine by t....he student.... o seperate Officer, KSOU, Manasacanzotri, Mysore 06 receipt wall be issued
I declare that the information furnished above by me is correct to the best of my knowledge....
Place
Date
Signature of the Candidate
CERTIFICATE
Certified that the attendance of the above candidate is satisfactory and he has fulfilled all the mandatory requirement of submission of Assignments Tests Practice teaching & submission of the Project Report (for Second year M....Ed students only)
Place
Date Signature of the Coordinator with seal
Instructions to the Candidate
0.... The Examination Application Form along with fee paid challanDD should be submitted to the respective study centres of Karnataka State Open University....
02.... The fee paid challan along with the application should be submitted on or before the due date (with or without penal fee as prescribed).... Otherwise the application will not be registered for examination....
03.... Incomplete applications are liable to be rejected....
04.... Examination fees once paid will not be readjusted refunded under any circumstances....
05.... Students who have not attended the Contact Programme or not submitted the Assignment or not taken the Tests or not completed Practice Teaching or who have not submitted the Project report (Second year M....Ed. students only) are not eligible to take the Examination even if they have paid the Examination Fee....
06.... Candidates will have to take Practical Examination before taking the Theory Examination....
I declare that the information furnished above by me is correct to the best of my knowledge.
Place:
Date :
Signature of the Candidate

CERTIFICATE
Certified that the attendance of the above candidate is satisfactory and he has fulfilled all the mandatory requirement of submission of Assignments I Tests I Practice teaching & submission of the Project Report (for Second year M.Ed students only)
Place:
Date: Signature of the Co-ordinator with seal
Instructions to the Candidate
01. The Examination Application Form along with fee paid challan I DD should be submitted to the respective study centres of Karnataka State Open University.
02. The fee paid challan along with the application should be submitted on or before the due date (with or without penal fee as prescribed). Otherwise the application will not be registered for examination.
03. Incomplete applications are liable to be rejected.
04. Examination fees once paid will not be re-adjusted I refunded under any circumstances.
05. Students who have not attended the Contact Programme or not submitted the Assignment or not taken the Tests or not completed Practice Teaching or who have not submitted the Project report (Second year M.Ed students only) are not eligible to take the Examination even if they have paid the Examination Fee.
06. Candidates will have to take Practical Examination before taking the Theory Examination.