Application Form For Duplicate Marksheet

KARNATAKA STATE OPEN UNIVERSITY
Mukthagangotri, Mysore – 570 006, Karnataka, India
www.ksoumysore.edu.in
To,
The Registrar (Evaluation), Academic Collaborator:______________________
Mukthagangotri, Mysore (Karnataka)
Sub.: APPLICATION FOR DUPLICATE MARKSHEET
1. Applicant’s Details:
Reg. No. / Enrol. No.: ____________________________________
Name :____________________________________
Father’s Name :____________________________________
Mother’s Name :____________________________________
Address :____________________________________
______________________________________________________
Pincode : ________________ Ph. No.:____________________
Email : ________________________________________________
2. Study Center:
Center Code : KSOU / ________________________________
Name : ______________________________________
Address : ______________________________________
______________________________________________________
______________________________________________________
City : ____________________ State : _____________________
Pincode : ________________ Ph. No.:_____________________
Email : ________________________________________________
3. Details of Particulars of Marksheet:
4. Reason (Indicate briefly the reason or obtaining above Marksheet) :
5. Details of fees paid : (Rs. 200/- per Marksheet)
DD/Challan No. DD Date DD Amount(Rs.) Bank Name (DD should be payable at Mysore)
Sr.No. Course Stream Semester Session Result
6. Declaration by the Applicant :
a. I certify that I have read and understood all the provisions indicated in the prospectus
and the Circulars published in the website www.ksoumysore.edu.in from time to time.
b. I certify that after being fully satisfied with this course I had decided to get enroled out
of my own free will and desire.
c. I further certify that same had been without any inducement and misrepresentation
either from the said University or any other person concerned.
d. I shall abide by this undertaking and shall not hold anybody responsible for the same
in any manner after the completion of the course.
e. I hereby certify that all the particulars stated in this application are true to the best of
my knowledge & belief. In the event of suppression or distortion of any fact made in
my application only I will be held responsible.
f. I understand that FEES once paid will NOT be refunded.
Signature of the Applicant:____________________
7. Seal & Signature of Study
Center Coordinator:
8. Seal & Signature of Academic
Collaborator:
For Office Use
Fees Received: __________________________
Document verified: __________________________
Dispatched on References: __________________________
Signature of Registrar (Evaluation)
Date :
INSTRUCTIONS
1. DD should be in the Name of “The Finance Officer, Karnataka State Open University”, Payable at Mysore.
2. Documents required.
i) Original Marksheet to be corrected.
th ii) For name correction please attach Photo Copy of 10 Marksheet duly attested.

FORMAT OF THE AFFIDAVIT (Incase of Lost of Marksheet)
(on Rs. 15/- Judicial Stamp Paper)
Before the Registrar Evaluation, Karnataka State Open University, Mysore.
_____________________________________________ (Name of the Student) ____________________________________________ deponent
I,__________________________________________, son/ daughter/wife of_____________ __________________________________________
aged______________________________ residing at _________________________________________________________________________
solemnly affirm and state as follows :
1. I say that I have lost the originals of the following Marksheet issued by the Karnataka State Open University, Mysore. I hereby attach the copy of
FIR lodged with the police/ (other forms of complaints lodged if any)
Reg No.(Enrollment No.) Particulars of the Marksheet lost
FIR No. Particulars of the FIR Report
2. I say that in spite of diligent search I am unable to trace the originals of the aforesaid Marksheets and hence they are taken as lost. If traced, I will produce them before the
University.
3. I say that I have not misused the same and I shall not misuse the same if recovered.
4. I say that for the purpose of _______________________________________________________________________________I need the certified duplicates of the
said Marksheet.
5. It is therefore necessary that on the strength of this affidavit certified duplicates are issued to me by the University.
6. All this is true.
Signature of the DEPONENT
Solemnly affirmed and signed before me on this day of __________________________________________________________________________
_________________________________________________ Dt ________________________________________________________________
NOTARY PUBLIC