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Price: Rs. 120/- ** * ** Appl. No.

_____________

PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ, zsÁgÀªÁqÀ


Passport Size
KARNATAK UNIVERSITY, DHARWAD Photograph
¥ÀzÀ« ¥ÀæªÀiÁt ¥ÀvÀæ ¥ÀqÉAiÀÄ®Ä ¸À°è¸ÀĪÀ Cfð
Application Form for Degree Certificate

1. ¥ÀzÀ«AiÀÄ ºÉ¸ÀgÀÄ
ªÁ¶ðPÀ / «±ÉõÀ WÀnPÉÆÃvÀìªÀzÀ ¥ÀzÀ« ¥ÀæzÁ£À Name of the Degree____________________
Annual / Special Convocation for Conferring Degrees 2. ¥Á¸ÁzÀ ±ÉæÃtÂ
PÀÄ®¸ÀaªÀgÀÄ(ªÀiË®åªÀiÁ¥À£À), PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ, zsÁgÀªÁqÀ Class obtained ________________
The Registrar(Evaluation), Karnatak University, Dharwad 3. ¥Á¸ÁzÀ ªÀµÀð
Year of passing ________________________
4. ¥sÀ°vÁA±À ¥ÀæPÀn¹zÀ ¢£ÁAPÀ
Date of declaration of result _____________
ªÀiÁ£ÀågÉ / Sir,
£Á£ÀÄ _______________gÀ r¸ÉA§gÀ/ªÀiÁZÀð wAUÀ½£À°è £ÀqÉAiÀÄ°gÀĪÀ «±Àé«zÁå®AiÀÄzÀ WÀnPÉÆÃvÀìªÀzÀ°è ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä Cfð ¸À°è¸ÀÄwÛzÉÝãÉ.
I am applying for the Degree at the University Convocation to be held in December / March _________________
F PɼÀUÉ £ÀªÀÄÆ¢¹zÀ ¥ÀzÀ«AiÀÄ ¥ÀæªÀiÁt ¥ÀvÀæ PÉÆÃj £Á£ÀÄ EzÀPÀÆÌ ªÉÆzÀ®Ä Cfð ¸À°è¹gÀĪÀ¢®è.
I have not applied for conferring the Degree mentioned below prior to this application.
£Á£ÀÄ ¥ÀzÀ« ¥ÀæªÀiÁt ¥ÀvÀæPÉÌ CUÀvÀå«gÀĪÀ J®è ªÀiÁ»wUÀ¼À£ÀÄß F PɼÀUÉ PÁt¹zÉÝãÉ.
All the particulars required for conferring the degree are prescribed below :
C.£ÀA. «ªÀgÀUÀ¼ÀÄ C¨sÀåyðAiÀÄÄ ¨sÀwð ªÀiÁqÀ¨ÉÃPÀÄ
Sl. No. Particulars To be filled by the candidate
C¨sÀåyðAiÀÄ ¥ÀÆtð ºÉ¸ÀgÀÄ (CAPÀ¥ÀnÖAiÀÄ°èzÀÝAvÉ)
1
Name of the candidate(as per Marks Card)
2 UÀAqÉÆÃ/ºÉuÉÆÚà - Male / Female
ªÀĺÁ«zÁå®AiÀÄzÀ ºÉ¸ÀgÀÄ, PÉÆÃqÀ £ÀA./¸ÁßvÀPÉÆÃvÀÛgÀ «¨sÁUÀzÀ ºÉ¸ÀgÀÄ
3
Name of the College with code No. /P.G. Dept.
C¨sÀåyðAiÀÄÄ ¥ÀqÉAiÀÄ°gÀĪÀ ¥ÀzÀ« / r¥ÉÆèêÀiÁzÀ ºÉ¸ÀgÀÄ
4
Name of the Degree/ Diploma for which applied
5 ¥Á¸ÁzÀ ªÀUÀð / Class obtained

6 ¥ÀjÃPÉëUÉ PÀĽvÀ ¸ÀܼÁAPÀ / Exam. Seat No.


¥ÀjÃPÉë ¥Á¸ÁzÀ wAUÀ¼ÀÄ ªÀÄvÀÄÛ ªÀµÀð
7
Month & year of passing the examination
¤AiÀÄ«ÄvÀ «zÁåyðAiÀiÁV / ¨ÁºÀå C¨sÀåyðAiÀiÁV
8 ¥ÀjÃPÉëAiÀÄ£ÀÄß ¥Á¸ÁVgÀĪÀzÀÄ
As a Regular/ External candidate
G¥À¹ÜvÀj zÀÄÝ / C£ÀÄ ¥À¹ÜvÀj zÀÄÝ ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä CºÀðjgÀÄ ªÀgÀÄ
9 Whether applicant held eligible to take the Degree in
“Person” or in “Absentia”
10 gÁ¶ÖçÃAiÀÄvÉ/ Nationality
zÀÈrüÃPÀÈvÀ CAwªÀÄ ªÀµÀðzÀ ¥Á¸ÁzÀ CAPÀ¥ÀnÖAiÀÄ£ÀÄß
F WÀnPÉÆÃvÀìªÀzÀ CfðAiÀÄ eÉÆvÉUÉ ®UÀwÛ¸À¨ÉÃPÀÄ.
11
Attested copy of the Final year Marks Card should be
enclosed with the Convocation Application.
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ACKNOWLEDGEMENT
Sl. No. of Application: ________________
Received the Convocation application form from Shri/Smt. _____________________________________________
_____________________for the Degree of _____________________ today he____________________________________

1. Degree : _______________________

2. Exam Seat No. : _______________________


3. Class : _______________________ Enquiry Counter
Examination Section
4. Year of passing : _______________________ Karnatak University, Dharwad
5. Date of declaration : _______________________

Note: 1. Bring the attested copies of the final year marks card and convocation fees paid challan/online fees receipt for
enquiry in.
2. If there are any corrections in degree certificates, candidates shall submit the same for corrections within three months
along with necessary enclosures from the date of receipt by post/by hand.
-2-
¥ÀÆtð ºÉ¸ÀgÀÄ (PÉÆ£ÉAiÀÄ ªÀµÀðzÀ CAPÀ ¥ÀnÖAiÀÄ°è EzÀÝAvÉ) (PÀ£ÀßqÀ ªÀÄvÀÄÛ EAVèõÀ JgÀqÀÆ ¨sÁµÉAiÀÄ°è PÀqÁØAiÀĪÁV §gɬÄj.)
Full name (as per Final Year Marks Card) (Write in Kannada and English version compulsory)
1. C¨sÀåyðAiÀÄ ºÉ¸ÀgÀÄ :
Name of the candidate

2. vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ :
Father’s name
3. vÁ¬ÄAiÀÄ ºÉ¸ÀgÀÄ :
Mother’s name

4. CqÀØ ºÉ¸ÀgÀÄ :
Surname

«±ÉõÀ. ¸ÀÆZÀ£É:
1. ¥ÀzÀ« ¥ÀæªÀiÁt ¥ÀvÀæªÀ£ÀÄß PÀ£ÀßqÀ ºÁUÀÆ DAUÀè JgÀqÀÆ ¨sÁµÉAiÀÄ°è ¤ÃqÀ°zÀÄÝ, C¨sÀåyðAiÀÄÄ WÀnPÉÆÃvÀìªÀPÉÌ CfðAiÀÄ£ÀÄß ¸À°è¸ÀĪÁUÀ
CAPÀ¥ÀnÖAiÀÄ°è £ÀªÀÄÆ¢¹zÀAvÉ vÀªÀÄä ¥ÀÆtð ºÉ¸ÀgÀ£ÀÄß PÀ£ÀßqÀ ºÁUÀÆ DAUÀè JgÀqÀÆ ¨sÁµÉAiÀÄ°è PÀqÁØAiÀĪÁV ¸ÀàµÀÖªÁV §gÉAiÀÄĪÀÅzÀÄ.
2. ¤UÀ¢¥Àr¹zÀ ±ÀĮ̪À£ÀÄß «±Àé«zÁå®AiÀÄzÀ CAvÀeÁð®zÀ°ègÀĪÀ SBI Portal UÀ¼À ªÀÄÄSÁAvÀgÀ e-payment ªÀiÁqÀĪÀ ªÀÄÆ®PÀ CxÀªÁ
C¢ü¸ÀÆZÀ£ÉAiÀÄ°è PÁt¹zÀ «±Àé«zÁå®AiÀÄzÀ “«vÁÛ¢üPÁjUÀ¼ÀÄ, PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ, zsÁgÀªÁqÀ” EªÀgÀ ºÉ¸ÀjUÉ EgÀĪÀ ¨ÁåAPÀÄUÀ¼À SÁvÉUÉ £ÉÃgÀ
ªÀUÁðªÀuÉ (Direct transfer) ªÀiÁqÀĪÀ ªÀÄÆ®PÀ ªÀiÁvÀæ ¨sÀgÀt ªÀiÁqÀ§ºÀÄzÁVzÉ. ±ÀÄ®Ì ¨sÀgt ªÀiÁrzÀ ±ÀÄ®Ì gÀÆ________ gÀ²Ã¢
£ÀA. ________________ ¢£ÁAPÀ __________________ ªÀÄÆ®PÀ vÀÄA§¯ÁVzÉ.
Special Instructions :
1. While filling application for convocation the candidate should write his/her name both in Kannada and English Version
compulsory, so as to enable us to write Kannada and English Version his/her name in the Degree Certificate.
2. The prescribed fees should be remitted either through the process of e-payment by logging to SBI Portal at the University
website or by transferring of amount through the Direct transfer the University accounts in the mentioned in notification in
favour of the Finance Officer, Karnatak University, Dharwad. Remitted of fess Rs. ____________receipt
No. __________________ dated ______________.
ªÉÄð£À ºÉýPÉAiÀÄÄ ¸ÀªÀÄ¥ÀðPÀªÁVzÉAiÉÄAzÀÄ £Á£ÀÄ F ªÀÄÆ®PÀ WÉÆö¸ÀÄvÉÛãÉ.
I declare that the statements made above are correct.
vÀªÀÄä «±Áé¹
Yours faithfully

C¨sÀåyðAiÀÄ ¸À»
Signature of the candidate
CAZÉ «¼Á¸À: Address for correspondence (in capital) : (Compulsory/ PÀqÁØAiÀĪÁVzÀÄÝ)

Candidate Name: ____________________________________________

____________________________________________

____________________________________________

____________________________________________

Pin Code : ________________________ Cell No.____________________


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1. ªÀÄzÀĪÉAiÀiÁzÀ ºÉtÄÚ ªÀÄPÀ̼ÀÄ UÀAqÀ£À ºÉ¸ÀgÀ£ÀÄß ¥ÀqÉzÀÄPÉÆAqÀ CxÀªÁ AiÀiÁªÀÅzÉà ªÀåQÛ ¨ÉÃgÉAiÀĪÀjUÉ zÀvÀÄÛ ºÉÆÃzÀ ¥Àæ¸ÀAUÀªÀ£ÀÄß ºÉÆgÀvÀÄ¥Àr¹ ºÉ¸Àj£À°è
§zÀ¯ÁªÀuÉ ªÀiÁqÀĪÀÅzÀPÉÌ C£ÀĪÀÄw¬Ä®èzÉ «zÁåyðUÀ¼ÀÄ F ªÉÆzÀ®Ä «±Àé«zÁå®AiÀÄzÀ°è zÁR¯ÁzÀ ºÉ¸Àj£ÉÆA¢UÉ ¥ÀvÀæ ªÀåªÀºÁgÀ ªÀiÁqÀ¨ÉÃPÀÄ.
Change in name is not permitted as in the case of women adopting the name of her husband or in the case of person changing the
name after he goes in adoption to some other person. The candidate should however correspond with the name that is already
recorded in the University.

2. C¨sÀåyðUÀ¼ÀÄ vÀªÀÄä ºÉ¸ÀgÀ£ÀÄß ¸ÀàµÀÖªÁV §gÉAiÀĨÉÃPÀÄ. CfðAiÀÄ°è §gÉzÀ ºÉ¸ÀgÀÄ «±À«


é zÁå®AiÀÄzÀ zÁR¯ÉAiÀÄ°è £ÀªÀÄÆ¢¸À¯ÁzÀ ºÉ¸ÀjUÉ ¸Àj ºÉÆAzÀ¢zÀÝ°è
¸ÀzÀgÀ Cfð gÀzÁÝUÀĪÀzÀÄ. MAzÀÄ ªÉÃ¼É C¨sÀåyðAiÀÄ ºÉ¸Àj£À §zÀ¯ÁªÀuÉUÉ PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄzÀ PÀÄ®¸ÀaªÀgÀÄ C£ÀĪÀÄw PÉÆnÖzÀÝ°è D ¥ÀvÀæzÀ ªÀÄÆ®
¥ÀæwAiÀÄ£ÀÄß CªÀ£ÀÄ/CªÀ¼ÀÄ CfðAiÀÄ eÉÆvÉUÉ ºÁdgÀ ¥Àr¸À¨ÉÃPÀÄ.
Candidates shall write their names legibly. If the name written in the application does not tally exactly with that of the University
records, the application will be rejected unless the candidate submits with the application the original letter from the Registrar,
Karnatak University permitting him/her for the change in name.

3. C¨sÀåyðAiÀÄÄ vÀ£Àß «¼Á¸ÀªÀ£ÀÄß ¥ÀÄl¸ÀASÉå 02 ªÀÄvÀÄÛ 04 gÀ°è CªÀ±ÀåªÁV/ PÀqÁØAiÀĪÁV £ÀªÀÄÆ¢¸ÀĪÀÅzÀÄ.


Address should be written by the candidate on page no. 2 and 4 compulsorily.

4. ¥ÀæxÀªÀÄ ªÀUÀðzÀ°è ¥Àæ±À¹Û ¸À»vÀ ¥ÀqÉzÀ ¸ÁÜ£À, ¥ÀæxÀªÀÄ ªÀUÀð, ¢éwÃAiÀÄ ªÀUÀð CxÀªÁ ¸ÁªÀiÁ£Àå (vÀÈwÃAiÀÄ) ªÀUÀðzÀ°è ¥Á¸ÁzÀÄzÀPÉÌ PÀæªÀiÁAPÀ 5 gÀ JzÀÄjUÉ
£ÀªÀÄÆ¢¸ÀĪÀÅzÀÄ.
Write “First Class with Distinction, First, Second or Pass” as the case may be against item No. 5.

5. JA.©.©.J¸ï./©.¥sÁªÀiÁð./©.J.JA.J¸ï./©.r.J¸ï./©.JZï.JªÀiï.J¸ï./©.¦.n. ¥ÀzÀ«AiÀÄ C¨sÀåyðUÀ¼ÀÄ ºË¸ÀªÀÄ£ï ²¥ï ªÀÄvÀÄÛ EAl£Àð²¥ï


¥ÀÆwðUÉƽ¹zÀ §UÉUÉ «±Àé«zÁå®AiÀÄ¢AzÀ ¥ÀqÉzÀ ¥ÀæªÀiÁt ¥ÀvÀæ ®UÀwÛ¸ÀĪÀÅzÀÄ.
6. Candidates of M.B.B.S. /B.Pharma/B.A.M.S./B.D.S./B.H.M.S. and B.P.T. courses have to enclose their compulsory Housemanship
/Internship Completion Certificate issued by the University.
7. PÀ««UÉ/ ¥ÀjÃPÁë «¨sÁUÀPÉÌ ¸ÀAzÁAiÀÄ ªÀiÁrzÀ ±ÀĮ̪À£ÀÄß AiÀiÁªÀÅzÉà PÁgÀt¢AzÀ ªÀÄgÀ½ ¤ÃqÀ¯ÁUÀĪÀ¢®è.
The fees once paid will not be refunded.

¸ÁßvÀPÀ / ¸ÁßvÀPÉÆÃvÀÛgÀ ¥ÀzÀ« ºÁUÀÆ r¥ÉÆèêÀiÁUÀ½UÉ ¸ÀA§A¢ü¹zÀ ¥ÀæªÉñÀ ±ÀĮ̪ÀÅ F PɼÀV£ÀAwzÉ :


Following are the Fees for issue of Original Degree Certificate of all the Degrees and Diploma Courses :

1. J®è ¤AiÀÄ«ÄvÀ ¸ÁßvÀPÀ, ¸ÁßvÀPÉÆÃvÀÛgÀ r¥ÉÆèêÀiÁ ºÁUÀÆ gÁåAPÀ «eÉÃvÀ ¥ÀzÀ« C¨sÀåyðUÀ¼ÀÄ ¨ÁºÀå C¨såÀ yðUÀ¼À£ÀÄß
ºÉÆgÀvÀÄ¥Àr¹ ¸ÀªÀÄPÀëªÀÄ ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä (¥Àæ¸ÀÄÛvÀ ±ÉÊPÀëtÂPÀ ªÀµÀðzÀ°è GwÛÃtðgÁzÀ «zÁåyðUÀ½UÉ ªÀiÁvÀæ)
In person - all regular P.G./ P.G. Diploma candidates & Rank holders in Rs 1185-00
Bachelor Degrees except External candidates (Current year successful candidates only)

2. J®è ¸ÁßvÀPÀ / ¸ÁßvÀPÉÆÃvÀÛgÀ r¥ÉÆèêÀiÁ ºÁUÀÆ ¥Àz«


À C¨sÀåyðUÀ¼ÀÄ C£ÀÄ¥À¹ÜvÀ ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä (ªÀiÁvÀæ)

In Absentia – U.G. ./ P.G. Diploma & Bachelor Degree candidates only Rs. 1185-00

1. G¥À¹ÜvÀ - ¸ÁßvÀPÉÆÃvÀÛgÀ «zÉò «zÁåyðUÀ½UÉ ªÀiÁvÀæ 185 qÁ®gïUÀ¼ÀÄ


2. C£ÀÄ¥À¹ÜvÀ - J®è ¥ÀzÀ«AiÀÄ «zÉò «zÁåyðUÀ½UÉ 185 qÁ®gïUÀ¼ÀÄ
(i) In person PG foreign students only US $ 185-00
(ii) In Absentia for all U.G. courses Foreign students only US $ 185-00

3. »A¢£À ªÀµÀðUÀ¼À°è vÉÃUÀðqÉAiÀiÁzÀªÀgÀÄ ¸ÀºÀ Cfð ¸À°è¸§


À ºÀÄzÀÄ. DzÀgÉ ±ÀÄ®ÌzÀ «ªÀgÀªÀ£ÀÄß «ZÁgÀuÁ ªÀĽUÉ, WÀnPÉÆÃvÀìªÀ «¨sÁUÀ
(0836-2215256) ºÁUÀÆ ªÉ¨ï¸ÉÊmï£À°ègÀĪÀ (www.kud.ac.in) ±ÀÄ®ÌzÀ AiÀiÁ¢¬ÄAzÀ ¥ÀqÉAiÀħºÀÄzÀÄ.
Successful candidates belonging to previous years are also eligible to apply for the ensuing Convocation, however they
are required to obtain the information about convocation fees from the Counter/ Convocation Section (0836-
2215256)/chart in the website:www.kud.ac.in.

C¨sÀåyðAiÀÄ ¸À»
Signature of the candidate
4
«¸ÉõÀ ¸ÀÆZÀ£É:

1. «zÉò «zÁåyðUÀ¼ÀÄ ±ÀÄ®ÌzÀ ºÀtªÀ£ÀÄß qÁ®gïUÀ½UÉ ¸ÀªÀÄ£ÁzÀ ¨sÁgÀwÃAiÀÄ gÀÆ¥Á¬ÄUÀ¼À°è ¥ÁªÀw¸ÀĪÀÅzÀÄ.


2. ¤UÀ¢¥Àr¹zÀ ±ÀĮ̪À£ÀÄß «±Àé«zÁå®AiÀÄzÀ CAvÀeÁð®zÀ°ègÀĪÀ SBI Portal UÀ¼À ªÀÄÄSÁAvÀgÀ e-payment ªÀiÁqÀĪÀ ªÀÄÆ®PÀ CxÀªÁ
C¢ü¸ÀÆZÀ£ÉAiÀÄ°è PÁt¹zÀ «±Àé«zÁå®AiÀÄzÀ “«vÁÛ¢üPÁjUÀ¼ÀÄ, PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ, zsÁgÀªÁqÀ” EªÀgÀ ºÉ¸ÀjUÉ EgÀĪÀ ¨ÁåAPÀÄUÀ¼À SÁvÉUÉ
£ÉÃgÀ ªÀUÁðªÀuÉ (Direct transfer) ªÀiÁqÀĪÀ ªÀÄÆ®PÀ ªÀiÁvÀæ ¨sÀgÀt ªÀiÁqÀ§ºÀÄzÁVzÉ.
3. ¥ÀzÀ« ¥ÀæªÀiÁt¥ÀvÀæUÀ¼À£ÀÄß ¸ÀªÀÄPÀëªÀÄ ¥ÀqÉAiÀÄ®Ä Cfð ¸À°è¹ WÀnPÉÆÃvÀìªÀzÀ ¢£ÀzÀAzÀÄ ¥ÀzÀ« ¥ÀæªÀiÁt¥ÀvÀæªÀ£ÀÄß ¥ÀqÉAiÀÄ¢zÀÝ°è CAxÀªÀgÀ£ÀÄß
UÉÊgÀºÁdj(C£ÀÄ¥À¹Üw) C¨sÀåyðUÀ¼ÉAzÀÄ ¥ÀjUÀt¸À¯ÁUÀĪÀzÀÄ.
4. CAwªÀÄ CAPÀ¥ÀnÖAiÀÄ°è ºÉ¸ÀgÀÄ/ºÉ¸Àj£À CPÀëgÀUÀ¼À°è K£ÁzÀgÀÆ wzÀÄÝ¥ÀqÉ ªÀiÁqÀĪÀÅ¢zÀÝ°è WÀnPÉÆÃvÀìªÀzÀ Cfð¸À°è¸ÀĪÀzÀQÌAvÀ ªÉÆzÀ¯Éà wzÀÄÝ¥ÀqÉ
ªÀiÁrPÉƼÀî¨ÉÃPÀÄ.

Special Instructions:

1. The foreign students can pay the equivalent amount of fees in Indian currency.
2. The prescribed fees should be remitted either through the process of e-payment by logging to SBI Portal at the University
website or by transferring of amount through the Direct transfer the University accounts in the mentioned in notification in
favour of the Finance Officer, Karnatak University, Dharwad.
3. The persons who have applied for conferring of the degree certificate in person but did not obtain his/her certificate on
convocation day, will be treated as in absentia
4. Any corrections in the name/spellings in the statement of marks at the final year shall be got corrected before submission
of convocation application.

__________________________________________________________________________________________________________

PÀZÉÃjAiÀÄ°è ¨sÀwð ªÀiÁqÀĪÀzÀÄ :


To be filled in by the Office :

1. ¥sÀ°vÁA±À ¥ÀæPÀn¹zÀ ¢£ÁAPÀ : Date Month Year C¢üÃPÀëPÀgÀÄ, ¸ÀA§A¢ü¹zÀ «¨sÁUÀ


Result declared on : O. S. Concerned Branch

2. WÀnPÉÆÃvÀìªÀzÀ CfðAiÀÄ£ÀÄß ¥Àj²Ã°¹zÀªÀgÀÄ ¸À»/ Signature __________________________


Convocation application verified by
ºÉ¸ÀgÀÄ / Name

From:-

The Registrar(Evaluation)
Karnatak University,
Pavate Nagar, Dharwad-580 003
Karnataka – India.

Candidate’s write address for dispatch of degree certificate-Compulsory ( in capital letters)


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O.I.G.S.
Karnatak University, Dharwad

To
Candidate Name:_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Pin Code : _________________ Cell No._____________________