KARNATAKA STATE OPEN UNIVERSITY
MUKTHAGANGOTRI, MYSORE - 570 006
APPLICATION FOR EXAMINATION
PG Diploma, Diploma & Certificate Examination ................................................................201........

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.
Mobile No:.................................................... Landline No:.................................................. Email ID:........................................................
Name of the Examination Centre
1. Name of the Candidate (in block letters):
(as in qualifying examination records)
2. Permanent Postal Address with pin code
(in block letters)
Pin Code:
3. Subjects / Papers for which to appear - (compulsorily indicate Reg. No., Year and Month of passing the previous examinations, if any) (‘P’ for assed, ‘A’ for appearing)
A/P Subjects Year &
Month
S.C S.T
Cat
I
Cat
IIA
Cat
IIB
Cat
IIIA
Cat
IIIB
5. do you belong to G.M. PH
(mark( ) to which you belong
6. Sex: Male / Female 7. Medium: English


Year of Admission ROLL / I.D. CARD NO.
KSOU COPY
Karnataka State Open University, Mysore
Name of the Bank &
Place of Remittance .......................................................
Name of the Course P.G.Diploma / Diploma / Certificate
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
ORIGINAL
SBM, Mukthagangotri, Mysore - 06
SBI, New Sayyaji Rao Road, Mysore-01
Name and Address of the Student
Amount Rs.
501: Examination Fee ::::
Penal Fee ::::
Change of Centre Fee :
Total
Amount (in words) Rupees ......................................................
Note: Fees once paid will not be Refunded.
Date: Signature of the Remitter
For the use of the Bank
The Amount of Rupees (in words)............................................
has been received
Challan No.
Date & Signature of the Officer
Bank Seal receiving the money
UNIVERSITY COPY
Not to be seperated from the Form
% % %
BANK COPY
Karnataka State Open University, Mysore
Name of the Bank &
Place of Remittance .......................................................
Name of the Course P.G.Diploma / Diploma / Certificate
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
Duplicate
SBM, Mukthagangotri, Mysore - 06
SBI, New Sayyaji Rao Road, Mysore-01
Name and Address of the Student
Amount Rs.
501: Examination Fee ::::
Penal Fee ::::
Change of Centre Fee :
Total
Amount (in words) Rupees ........................................................
Note: Fees once paid will not be Refunded.
Date: Signature of the Remitter
For the use of the Bank
The Amount of Rupees (in words)..............................................
has been received /
Challan No.
Date & Signature of the Officer
Bank Seal receiving the money
To be retained with the receiving bank
% % %
SBM/SBI, MYSORE COPY
Karnataka State Open University, Mysore
Name of the Bank &
Place of Remittance .......................................................
Name of the Course P.G.Diploma / Diploma / Certificate
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
Triplicate
SBM, Mukthagangotri, Mysore - 06
SBI, New Sayyaji Rao Road, Mysore-01
Name and Address of the Student
Amount Rs.
501: Examination Fee ::::
Penal Fee ::::
Change of Centre Fee :
Total
Amount (in words) Rupees ........................................................
Note: Fees once paid will not be Refunded.
Date: Signature of the Remitter
For the use of the Bank
The Amount of Rupees (in words)...............................................
has been received /
Challan No.
Date & Signature of the Officer
Bank Seal receiving the money
Receiving Bank should send this copy to the Finance
Officer, KSOU, Mukthagangotri, Mysore-06
% % %
STUDENT COPY
Karnataka State Open University, Mysore
Name of the Bank &
Place of Remittance .......................................................
Name of the Course P.G.Diploma / Diploma / Certificate
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
Quadruplicate
SBM, Mukthagangotri, Mysore - 06
SBI, New Sayyaji Rao Road, Mysore-01
Name and Address of the Student
Code No: Amount Rs.
501: Examination Fee ::::
Penal Fee ::::
Change of Centre Fee :
Total
Amount (in words) Rupees .......................................................
Note: Fees once paid will not be Refunded.
Date: Signature of the Remitter
For the use of the Bank
The Amount of Rupees (in words)............................................
has been received /
Challan No.
Date & Signature of the Officer
Bank Seal receiving the money
Student copy to be retained by the student. No seperate
receipt will be issued
Affix
Stamp Size
Photo here
I declare that the above information furnished by me is correct to the best of my knowledge.
Date...........................
.............................................
Place.......................... Signature of the Candidate
Accepted / Rejected FOR OFFICE USE ONLY
........................................................
Scrutinized by Checked by

IMPORTANT INSTRUCTIONS TO BE FOLLOWED BY THE CANDIDATES
01. Regarding the submission of filled-in application form read the instructions printed in the exam fee circular.
02. The fee paid challan and the application should be submitted on or before the due date (without or with penal fee as prescribed). Otherwise the application will not be registered for examination.
03. Incomplete applications are liable to be rejected.
04. The prescribed fee is to be remitted through the Challan, which is supplied by KSOU, in SBI/SBM Banks.
05. Examination fees once paid will not be re-adjusted / refunded under any circumstances.
06. Regarding the rates of Examination fees, Separate Circular is enclosed.
07. The application should be submitted to THE REGISTRAR (EVALUATION), Karnataka State Open University, Mukthagangotri, Mysore – 570 006.
08. MOBILE PHONES ARE PROHIBITED IN THE EXAMINATION HALL.
Note: i) Please read carefully the instructions given overleaf before filling up the application, as well as instructions in the fee circular.
ii) Strike off whichever is not applicable.
9. Details of fees paid:
Year Amount Paid Name of the Bank Challan No. Date