KARNATAKA STATE OPEN UNIVERSITY
MANASAGANGOTRI, MYSORE - 570 006
APPLICATION FORM FOR REGISTRATION
B.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.
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
Year of Admission ROLL / I.D. CARD NO.
Affix
Stamp Size
Photo here
KSOU COPY
Karnataka State Open University, Mysore
Name of the Bank &
Place of Remittance .......................................................
Name of the Course B.Ed...................................
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
ORIGINAL
SBM, Manasagangotri, 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 & S ignature 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 B.Ed...................................
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
Duplicate
SBM, Manasagangotri, 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
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 B.Ed...................................
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
Triplicate
SBM, Manasagangotri, 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
Receiving Bank should send this copy to the Finance
Officer, KSOU, Manasagangotri, Mysore-06
% % %
STUDENT COPY
Karnataka State Open University, Mysore
Name of the Bank &
Place of Remittance .......................................................
Name of the Course B.Ed...................................
Roll No:
KSOU-500-EXAMINATION FUND
SBM-54035420128 SBI-31106997538
Quadruplicate
SBM, Manasagangotri, 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
A/P Paper
No. Subjects Reg. No. Year &
Month A/P Paper
No. Subjects Reg.
No.
Year &
Month
4. CATEGORY
(mark( ) to which you belong S.C S.T Cat
I
Cat
IIA
Cat
IIB
Cat
IIIA
Cat
IIIB G.M.
7. Did you attend
5. Sex 6. Medium
i. Contact Programme ii. Submitted the
Assignment iii. Appeared for Test
Male / Female English / Kannada Yes N o Yes N o Yes N o
8. Year in which the candidate
completed the course
Amount Paid Date Name of the Bank
9. Details of fees paid:
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DECLARATION
I, .................................................................. hereby declare that the information furnished by me on the previous page is correct to the best of my knowledge.
Place: .............................
Date : ............................. . . ............................................
Signature of the Candidate
CERTIFICATE
Certified that the attendance of the above candidate during the Contact Programme was satisfactory and the candidate has fulfilled all the mandatory requirement of submission of Assignment & taking the Tests.
Place:
Date : Signature of the Co-ordinator with seal
Instructions to the Candidate
01. The Examination Application Form along with the Fee paid Challan / DD should be submitted to the respective Study Centers.
02. Incomplete applications are liable to be rejected.
03. The details of the Fee challan (with or without Penal Fee) should be furnished in the column provided in this Application Form (Item No. 10)
04. Details of Fees and the last date for payment of fee are given in the separate circular issued by the University.
05. Examination Fee once paid will not be re-adjusted / refunded under any circumstances.
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