Karnataka State Open University: Mukthagangotri

KARNATAKA STATE OPEN UNIVERSITY
Mukthagangotri, Mysore – 570 006, Karnataka, India
To,
The Registrar (Evaluation),
Karnataka State Open University, Academic Collaborator:_____________________________
Mukthagangotri, Mysore (Karnataka)
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APPLICATION FOR PROVISIONAL CERTIFICATE (DIPLOMA / UG / PG)
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1. Applicant’s Details & Address: 2. Study Center:
Name : ____________________________________ Center Code : KSOU/_________
Father’s/Husband Name: _____________________________ Name : ___________________________________
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Mother’s Name : ____________________________________ Address : ___________________________________
Address : ____________________________________ ___________________________________________________
FI
___________________________________________________ ___________________________________________________
___________________________________________________ City : ____________________ State : __________________
Pincode : ________________ Mob. No.:________________ Pincode : ________________
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3. Tel No.
(With STD Code): 4. Email :
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5. Name of the Examination : Diploma P.G.____________ U.G.____________
6. Stream : 7. Year of Passing :
8. Registration No. : Provisional Certificate

9. Request for the issue :
C
(Diploma/Degree)
10. Academic Details:

Course Stream Semester Month & year of Passing Semester Total Semester Grade
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ON
11. Reason (Indicate briefly the reason or obtaining above certificate) :

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12. Details of fees paid :

DD/Challan No. DD Date DD Amount(Rs.) Bank Name (DD should be payable at Mysore)
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13. Stamp & Sign of Coordinator of Study Center:

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Paste one recent passport size

Photograph
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14. Stamp of Academic Collaborator:
Specimen Signature of the Canditate
Pg. 1 of 2
15. Declaration By the Applicant :
a. I certify that I have read and understood all the provisions indicated in the prospectus and the Circulars published in the website
www.ksoumysore.edu.in from time to time.
b. I certify that after being fully satisfied with this course I had decided to get enroled out of my own free will and desire.
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c. I further certify that same had been without any inducement and misrepresentation either from the said University or any other
person concerned.
d. I shall abide by this undertaking and shall not hold anybody responsible for the same in any manner after the completion of the
course.
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e. I hereby certify that all the particulars stated in this application are true to the best of my knowledge & belief. In the event of
suppression or distortion of any fact made in my application only I will be held responsible.
f. I understand that FEES once paid will NOT be refunded.
For Office Use
IC
Eligibility verified and found correct YES / NO
Fees Received
Certificates verified
TIF
Despatched on
References ________________________________
Signature of Registrar (Evaluation)
ER Date :
INSTRUCTIONS
LC
Following documents must be forwarded along with the application :
a. Certified true copy of 10th or equivalent in case of Diploma students and 10+2 or equivalent in case of B.Tech students and
Degree pass certificate of M.Tech students. (Duly Notarized)
b. Copy of Fi nal pass certificate obtained from the University.(Duly Notarized)
c. Xerox copy of the Marks Sheet of all semesters. (Duly Notarized)
d. Original School Living Certificate in case of Diploma Student & Original Migration from Old University in case of Degree Student.
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Note : Along with all relevant documents & DD the application form should be submitted to the study center only.
DD should be in the Name of “The Finance Officer, Karnataka State Open University”, Payable at Mysore.
FEES
S. No. Description Fees

IO
UG Rs. PG Rs.
1. Provisional Pass Certificate (PPC) 400/- 450/-
2. Migration Certificate (Additional Rs.50/- search fee per year) 400/- 450/-
3. Consolidated Marks Card (Additional Rs. 50/- for delay per year) 300/- 350/-
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4. Convocation Fee (in Absentia) Additional Search fee per year Rs. 50/-) 700/- 750/-
5. Genuinety Certificate 400/- 450/-
6. Genuinety Certificate/Verification Certificate for overseas students 2000/-
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Pg. 2 of 2
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Karnataka State Open University: Mukthagangotri

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KARNATAKA STATE OPEN UNIVERSITY

Mukthagangotri, Mysore – 570 006, Karnataka, India

Father’s/Husband Name: _ Name : _______

Address : _______________

_________________________________ City : State :

Pincode : Mob. No.: Pincode :

6. Stream : 7. Year of Passing :

8. Registration No. : Provisional Certificate

10. Academic Details:

11. Reason (Indicate briefly the reason or obtaining above certificate) :

12. Details of fees paid :

13. Stamp & Sign of Coordinator of Study Center:

Paste one recent passport size

14. Stamp of Academic Collaborator:

Specimen Signature of the Canditate

For Office Use

Signature of Registrar (Evaluation)

S. No. Description Fees

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