KARNATAKA STATE OPEN UNIVERSITY

Mukthagangotri, Mysuru 570 006.

Application Form for Academic Collaborator Examination of_________ 20___

ROLL / ID CARD NO YEAR OF ADMISSION

COURSE : _____________________________ STREAM : _____________________

Affix a
Stamp size
SPECIALIZATION / ELECTIVE :___________________________________________ photograph

SEMESTER : ________ / YEAR ______________

NOTE : i) Please read carefully the instructions given overleaf filling up the application, as well as instructions in the fee circular.
ii) Strike off whichever is not applicable.

Name of the candidates (in block letters) :

(as in Matriculation Examination records)
Name of the Collaborator :

Study Centre Name & Code :

Subject / Papers for which to appear (indicate Reg. No. Year & Month of passing the previous examination,
if any) (P for Passed A for appearing).

A
A Paper Subject / Papers Year & Paper Subject / Papers Year &
/
/ No. (___________Year / Semester) Month No. (___________Year / Semester) Month
P
P

A A
Paper Subject / Papers Year & Paper Subject / Papers Year &
/ /
No. (___________Year / Semester) Month No. (___________Year / Semester) Month
P P
A A
Paper Subject / Papers Year & Paper Subject / Papers Year &
/ /
No. (___________Year / Semester) Month No. (___________Year / Semester) Month
P P

A A
Paper Subject / Papers Year & Paper Subject / Papers Year &
/ /
No. (___________Year / Semester) Month No. (___________Year / Semester) Month
P P

SEX : Male / FEMALE : _________ MEDIUM : __________________

Year in which candidate completed the Programme :

I Year / II Year / III Year / IV Year / V Year / VI Year / VII Year / VIII Year /
Semester Semester Semester Semester Semester Semester Semester Semester

Details of fees paid :

YEAR / SEMESTER Amount Paid Name of the bank DD / Journal No. Date

I declare that the information furnished by me is correct to the best of my knowledge.

Date : ________________

Place : _______________ Collaborator Institute Seal & Signature Signature of the Candidate

FOR OFFICE USE ONLY

Accepted / Rejected

Scrutinized by Checked by