gÁt ZÀ£ÀߪÀÄä «±Àé«zÁå®AiÀÄ, ¨É¼ÀUÁ« RANI CHANNAMMA UNIVERSITY, BELAGAVI

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Application Processing Fees: GM/OBC Rs. 400/- SC/ ST/Cat-1 Rs. 200/-

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¸ÁßvÀPÉÆÃvÀÛgÀ ¥ÀzÀ«/¸ÁßvÀPÉÆÃvÀÛgÀ r¥ÉÆèêÀiÁ/¸Ànð¦üPÉÃmï PÉÆøÀðUÀ¼À 2017-18 £Éà ±ÉÊPÀëtÂPÀ ¸Á°£À ¥ÀæªÉñÁw Cfð Application for Admission to Post Graduate Degree/PG Diploma & Certificate Courses for the academic year 2017-18

(Read the instructions carefully before filling the form form..Tick the relevant box and use capital letters only)

¥ÀæªÉñÁw §AiÀĸÀĪÀ «¨sÁUÀ/«µÀAiÀÄ: ___________________________________________________________________ Department/Subject:____________________________________________________________________________ Note : Please submit the application form to the concerned department along with all documents & original copy of the Challan

¸ÀÆZÀ£É: DAiÀiÁ «¨sÁUÀPÉÌ ¥ÀæªÉñÁw CfðAiÉÆA¢UÉ J®è ¥ÀæªÀiÁt ¥ÀvÀæUÀ¼ÀÄ ªÀÄvÀÄÛ ±ÀÄ®ÌzÀ ªÀÄÆ® rr eÉÆvÉUÉ ¸ÀÀ°è¸À¨ÉÃPÀÄ

C¨sÀåyðAiÀÄ «ªÀgÀUÀ¼ÀÄ

PARTICULARS OF THE CANDIDATE 1. «zÁåyðAiÀÄ ºÉ¸ÀgÀÄ (¥ÀzÀ« ¥ÀjÃPÉëAiÀÄ CAPÀ¥ÀnÖAiÀÄ°èzÀÝAvÉ): Name of the Applicant (As in the Degree Marks Card):

2. vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ: Father’s Name:

3. vÁ¬ÄAiÀÄ ºÉ¸ÀgÀÄ: Mother’s Name:

4. CqÀØ ºÉ¸ÀgÀÄ: Surname:

5. ¥ÀvÀæ ªÀåªÀºÁgÀzÀ «¼Á¸À: Address for the Correspondence: ____________________________________________________________________________________ ____________________________________________________________________________________ Contact No.:_______________________________Email-ID:____________________________________ DzsÁgÀ PÁqÀð ¸ÀASÉå: Aadhaar Card No. : ___________________________________ (compulsory) 1| P . G A p p l i c a t i o n F o r m 2 0 1 7 - 1 8 .

6. ªÁ¶ðPÀ DzÁAiÀÄ Annual Income

7. ªÀÈwÛ Occupation

: :

8. gÁ¶ÖçÃAiÀÄvÉ Nationality

: :

¨sÁgÀwÃAiÀÄ Indian

9. d£Àä ¢£ÁAPÀ Date of Birth

: :

D

D

: :

«zÉòAiÀÄgÀÄ Foreigner M

M

Y

Y

Y

Y

(As in SSLC Marks Card)

10. °AUÀ Gender

: UÀAqÀÄ : Male

11. ªÀUÀð: Category: ¸ÁªÀiÁ£Àå GM

¥À.eÁ SC

vÀÈwÃAiÀÄ °AUÀ Transgender

ºÉtÄÚ Female

¥À.¥ÀA ST

¥ÀæªÀUÀð Cat-I

II-J II-A

II-© II-B

III-J III-A

III-© III-B

12. F PɼÀV£À «ÄøÀ¯Áw ªÀUÀðUÀ¼À°è ¥ÀæªÉñÀ ¥ÀqÉAiÀÄ®Ä EaÒ¸ÀÄwÛgÁ?: Specify, if you are claming admission in the following quota: CAUÀ«PÀ® P.H

QæÃqÉ Sports

J£ï.¹.¹ NCC

ºÉÊ/PÀ H.K

J£ï.J ¸ï.J¸ï. NSS

¤ªÀÈvÀÛ ¸ÉʤPÀ Ex-Service Man

PÀ£ÀßqÀ ªÀiÁzsÀåªÀÄ Kannada Medium

EvÀgÉ «.« O.U

DvÀäºv À Éå ªÀiÁrPÉÆAqÀ gÁdåzÀ gÉÊvÀgÀ ªÀÄPÀ̼ÀÄ (gÁZÀ« C¨sÀåyðUÀ¼ÀÄ ªÀiÁvÀæ)

¹.r.¦.J¸ï Children of Defence/ Political Sufferers

¯ÉÊAVPÀ ±ÉÆõÀuÉUÉ M¼ÀUÁzÀ/ JZï.L.« ¦rvÀgÀ/ zÉêÀzÁ¹AiÀÄgÀ ªÀÄPÀ̽UÉ Children of Sexually Exploited/HIV/ Devadasi

dªÀÄÄä PÁ²äÃgÀ «zÁåyðUÀ½UÉ

13. F »AzÉ C¨sÀå¹¹zÀ ªÀĺÁ«zÁå®AiÀÄzÀ ºÉ¸ÀgÀÄ: Name of the College previously studied:

14. CºÀðvÁ ¥ÀjÃPÉëAiÀÄ «ªÀgÀ (ªÀÄÆ® ¨sÁµÁ «µÀAiÀÄUÀ¼À£ÀÄß ºÉÆgÀvÀÄ¥Àr¹ LaÒPÀ «µÀAiÀÄUÀ¼À CAPÀUÀ¼À£ÀÄß ªÀiÁvÀæ ¥ÀjUÀt¹):

· Register No. of the last qualifying exam: ________________ · Details of qualifying examination (enter the total marks obtained in optional subjects excluding the marks obtained in basic language): ¸ÁßvÀPÀ ¥ÀzÀ« ¤ÃrzÀ GwÛÃtðgÁzÀ ±ÉÃPÀqÁªÁgÀÄ ¥ÀjÃPÉë ¥ÀqÉzÀ CAPÀUÀ¼ÀÄ «±Àé«zÁå®AiÀÄzÀ ºÉ¸ÀgÀÄ UÀjµÀÖ CAPÀUÀ¼ÀÄ ªÀµÀð Percentage Exam Name of the University Max. Marks Marks obtained Passing Year as defined awarded UG Degree

2| P . G A p p l i c a t i o n F o r m 2 0 1 7 - 1 8 .

15. ¥ÀzÀ« ¥ÀjÃPÉëAiÀÄ LaÒPÀ «µÀAiÀÄ CAPÀUÀ¼À «ªÀg:À Details of the marks obtained in the concerned optional subject (Including Theory & Practical Marks): Sl. No.

Subject

I Semester

II Semester

III Semester

IV Semester

V Semester

VI Semester

MM

MM

MM

MM

MM

MM

MO

MO

MO

MO

MO

MO

Total Marks MM

%

MO

1

MM: Indicates Maximum Marks for the concerned subject/paper along with theory/practical (wherever applicable) MO: Indicates Marks Obtained in the concerned subject/paper along with theory/practical (wherever applicable)

16. ¥ÀæªÉñÁw Cfð ±ÀÄ®ÌzÀ «ªÀgÀu:É (rrAiÀÄ£ÀÄß ºÀtPÁ¸ÀÄ C¢üPÁjUÀ¼ÀÄ,gÁt ZÀ£ÀߪÀÄä «±Àé«zÁå®AiÀÄ, ¨É¼ÀUÁ« EªÀgÀ ºÉ¸Àj£À°è ¥ÀqAÉ iÀÄĪÀÅzÀÄ) Application Form Fee Details: (DD drawn in favour of the “Finance Officer, Rani Channamma University, Belagavi”) ªÉÆvÀÛ gÀÆ. r.r. ªÀÄvÀÄÛ ZÀ®£À ¸ÀASÉå/¢£ÁAPÀ ¨ÁåAPï ªÀÄvÀÄÛ ±ÁSÉ ºÉ¸ÀgÀÄ Amount Rs. D.D. and Challn No./Date Name of the Bank and Branch

17. CºÀðvÁ ¥ÀæªÀiÁt (Eligibility Certificate) ¥ÀvÀæzÀ CªÀ±ÀåPÀvÉ EzÉAiÀiÁ? : æ ÀiÁt ¥ÀvÀæªÀ£ÀÄß ¨ÉÃgÉ «±Àé«zÁå®AiÀÄ¢AzÀ ¥ÀzÀ« ¥ÀqÉzÀÄPÉÆArzÀÝgÉ CºÀðvÁ ¥Àª gÀÆ. 1100/- ¸ÀAzÁAiÀÄ ªÀiÁr ¥ÀqÉzÀÄPÉƼÀî¨ÉÃPÀÄ. (ªÀÄ»¼Á «±Àé«zÁå®AiÀÄ, «dAiÀÄ¥ÀÄgÀ ºÉÆgÀvÀÄ ¥Àr¹) Except KSWU Vijayapur & R.C.U Belagavi, it is mandatory for other university candidates to produce Eligibility Certificate by paying Rs. 1100/- at the time of submission of Application (Compulsory).

ºËzÀÄ Yes

E®è No

zÀÈrüÃPÀgÀt DECLARATION £Á£ÀÄ F PÉÆùð£À eÉÆvÉUÉ ¨ÉÃgÉ AiÀiÁªÀÅzÉà ¥ÀzÀ« PÉÆùðUÉ F «±Àé«zÁå®AiÀÄzÀ¯ÁèUÀ°Ã CxÀªÁ C£Àå ¸ÀA¸ÉÜUÀ¼À°è ¥ÀæªÉñÀ ¥ÀqÉ¢gÀĪÀÅ¢®èªÉAzÀÆ ºÁUÀÆ F CfðAiÀÄ°è £ÀªÀÄÆ¢¹zÀ ªÀiÁ»w ªÀÄvÀÄÛ CqÀPÀUÉƽ¹zÀ zÁR¯ÉUÀ¼ÀÄ £ÉÊdªÁVgÀÄvÀÛzÉAzÀÄ ¥ÀæªÀiÁtÂÃPÀj¸ÀÄwÛzÉÝãÉ. 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 JA§ÄzÀPÉÌ £Á£ÀÄ §zÀÞ£ÁVzÉÝãÉ. £Á£ÀÄ «±Àé«zÁå®AiÀÄzÀ J®è ¤AiÀĪÀÄ/«¤AiÀĪÀÄUÀ½UÉ §zÀÞ£ÁVzÉÝãÉ. I shall hereby solemnly affirm that, I am not pursuing any other degree/course in the University or outside the University simultaneously and further I state that the statements made and information furnished by me in this application and in the enclosures are true to the best of my knowledge. I shall hereby undertake to fulfil 75% of attendance in each course/paper to appear for the examination as per University norms and Admission Regulations. I also agree that there is no provision in the University rules to condone the shortage of attendance. I shall hereby agree to abide all the relevant rules and regulations of the University. ¢£ÁAPÀ: Date: 3| P . G A p p l i c a t i o n F o r m 2 0 1 7 - 1 8 .

«zÁåyðAiÀÄ ¸À» Signature of the Student

ENCLOSURES CHECK LIST 1. CºÀðvÁ ¥ÀjÃPÉëAiÀÄ/ºÉZÀÄѪÀj «zÁå¨sÁå¸ÀzÀ CAPÀ¥ÀnÖ EvÁå¢. Statement of Marks in respect of the qualifying examination and other qualifications, if any.

2. ºÀÄnÖzÀ ¢£ÁAPÀzÀ zÁR¯É. Date of Birth Certificate.

3. PÁ®A £ÀA. 11, ªÀÄvÀÄÛ 12 gÀ°è ºÉýzÀ ¸ÀAUÀwUÀ¼À ¸ÀªÀÄxÀð£ÉUÁV ¸ÀPÀëªÀÄ ¥Áæ¢üPÁgÀ¢AzÀ ¥ÀqÉzÀ ¥ÀæªÀiÁt ¥Àvz Àæ À ¥ÀæwUÀ¼ÀÄ. Photo copy of the Certificate issued by the competent authority (concerned Tahasildar), in support of the facts mentioned in Column Nos. 11 and 12.

4. «zÁåyðAiÀÄ ±ÉÊPÀëtÂPÀ zÁR¯ÁwUÀ¼ÀÄ. Academic Documents of Student.

«±ÉõÀ ¸ÀÆZÀ£É: 1. ¸ÀĸÀAUÀvÀ zÁR¯ÉUÀ¼À£ÀÄß ¸À°è¹zÀ°è ªÀiÁvÀæ ±ÀÄ®Ì jAiÀiÁ¬Äw ¸Ë®¨sÀå ¤AiÀĪÀiÁ£ÀĸÁgÀ ¤ÃqÀ¯ÁUÀĪÀzÀÄ. Fee concession is strictly against relevant documents. 2. «zÁåyðUÀ¼ÀÄ ¥ÀæªÉñÀ ¥ÀjÃPÉë ªÀÄvÀÄÛ ¥ÀæªÉñÀ ¥ÀqÉAiÀÄĪÀ ¸ÀªÀÄAiÀÄzÀ°è ¹éÃPÀÈw ¥ÀvÀæªÀ£ÀÄß PÀqÁØAiÀĪÁV ºÁdgÀ¥Àr¸À¨ÉÃPÀÄ. The candidates shall produce the ACKNOWLEDGEMENT at the time of Entrance Test.

PÁAiÀiÁð®AiÀÄzÀ G¥ÀAiÉÆÃUÀPÁÌV ªÀiÁvÀæ FOR OFFICE USE ONLY Application Received by:____________________________________________________ Date:_______________ (Name & Signature) Application Scrutinized by:__________________________________________________ Date:_______________ (Name & Signature) Remarks:_______________________________________________________ CHAIRPERSON

...........................................................................................................................................................................................................................................................

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¹éÃPÀÈw ¥ÀvÀæ ¥ÀæxÀªÀÄ ¸É«Ä¸ÀÖgï ¸ÁßvÀPÉÆÃvÀÛgÀ PÉÆùð£À 2017-18 £Éà ±ÉÊPÀëtÂPÀ ¸Á°UÁV _____________________________ «µÀAiÀÄzÀ°è ¥ÀæªÉñÀPÁÌV ¸À°è¹zÀ ²æÃ/²æêÀÄw _________________________________________________________ ____________________________________________________ AiÀĪÀgÀ Cfð £ÀA. __________________ £ÀÄß ¹éÃPÀj¸À¯ÁVzÉ. ¸ÀܼÀ: ¢£ÁAPÀ: 4| P . G A p p l i c a t i o n F o r m 2 0 1 7 - 1 8 .

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