PERSONAL DETAILS
APPLICATION NO. KU13012943
NAME LALITA PATGAR
FATHER NAME BOBBU PATGAR
DATE OF BIRTH : 05-04-1973 | GENDER : FEMALE | OCCUPATION:TEACHER
CATEGORY: GM | HANDICAP: NONE | NATIONALITY: INDIAN | ANNUAL INCOME: 304800
ADDRESS: W/O MAHADEV PATGAR, M ANAND RAO EXENSION,MILAGATTA, SHIVAMOGGA, SHIMOGA, 577201,
KARNATAKA
PHONE: 9481691170 | EMAIL: -
COURSE OPTED
GRADUATION: PG | COURSE: MA | SUBJECT :KANNADA
MEDIUM: KANNADA | LANGUAGES/ELECTIVES:-
SL Paper Title Paper Code Paper Type
1 c O DPA510 COMPULSORY
2 ._ DPA520 COMPULSORY
3 t,,. DPA530 COMPULSORY
CENTER DETAILS
STATE : KARNATAKA | DISTRICT : SHIMOGA
CENTER NAME : KUVEMPU UNIVERSITY - SHANKARAGHATTA | CENTRE CODE : 01
FEE DETAILS
PAYMENT MODE : SBM CHALLAN | AMOUNT: Rs.5150/-(FULL FEE),PROSPECTUS ALREADY PURCHASED
PAYMENT DATE: | REFERENCE NO: | SBM BRANCH:
BASIC QUALIFICATION DETAILS
QUALIFICATION : B.A | COMBINATION : HISTORY,KANNADA,SANSKRIT | ELECTIVES : KANNADA | REG NO. : 19635
MONTH-YEAR OF PASSING : 03-2010 | INSTITUTION/UNIVERSITY : DR. A V BALIGA ARTS & SCIENCE COLLEGE,KARNATAKA
UNIVERSITY,DHARWAD
DATE : 11-01-2014
PLACE : Signature of the Applicant
P.T.O.
PAGE-2
DECLARATION
I hereby solemnly and sincerely affirm that the statements made and information furnished in my application and also in
the enclosures submitted by me are true. Should it, however be found that the information furnished therein is not
factually true, I know that I am liable for prosecution and forfeiture of my admission. I have also taken note that once the
admission process is over, fee shall not be refunded by the university. In case of my grievances, I shall approach the
university and in case of any arbitration and any redressal of grievances I shall abide by the arbitration and territorial
jurisdiction clause laid in the prospectus.
Place :
Date :
Signature of the Applicant
Note: Candidates should send the filled up Application to the Director, DDE, Kuvempu University, Jnana Sahyadri,
Shankaraghatta 577451, Shimoga District, Karnataka along with the SBM Challan / N.E.F.T. Form and Relevant Documents.
KUVEMPU UNIVERSITY
DIRECTORATE OF DISTANCE EDUCATION
Jnana Sahyadri, Shankaraghatta-577451, Shimoga(D),
Karnataka
CHALLAN
Bank Copy
S.B.M POWER JYOTHY A/C NO. :64100999567
STATE BANK OF MYSORE, JNANASAHYADRI BRANCH
BRANCH CODE : 40759 IFSC CODE : SBMY0040759
BANK USE ONLY
Bank STATE BANK OF MYSORE
Branch Name
Branch Code
Journal NO.
Date
Reference NO. : KU13012943
Applicant Name: LALITA PATGAR
Address : W/o Mahadev Patgar, M Anand Rao
Exension,milagatta, Shivamogga, Shimoga, 577201, Karnataka
Course Subject Fee
MA KANNADA Rs.5150/-
Fee Paid : Full Fee
Amount In Words : Five Thousand One Hundred Fifty Only
PAID TO THE CREDIT OF FINANCE OFFICER, KUVEMPU UNIVERSITY, SHANKARAGHATTA, SHIMOGA
(D), KARNATAKA
A/C NO :64100999567 WITH SBM,JNANASAHYADRI SHANKARAGHATTA SHIMOGA
Particulars Course Fee Bank Charges Total
Amount Rs.5150/- Rs.50/- Rs.5200/-
Amount In Words :Five Thousand Two Hundred Only
Date : Signature of the Remitter
Received Rupees
Date & Seal Signature of the Receiver
1. Accepted at all the branches of SBM
2. Collecting Branch has to enter Reference No : & Name of the
Candidate for this transaction in core Banking System
3. Not Transferable.
KUVEMPU UNIVERSITY
DIRECTORATE OF DISTANCE EDUCATION
Jnana Sahyadri, Shankaraghatta-577451, Shimoga(D),
Karnataka
CHALLAN
DDE Copy - To be sent with application form
S.B.M POWER JYOTHY A/C NO. :64100999567
STATE BANK OF MYSORE, JNANASAHYADRI BRANCH
BRANCH CODE : 40759 IFSC CODE : SBMY0040759
BANK USE ONLY
Bank STATE BANK OF MYSORE
Branch Name
Branch Code
Journal NO.
Date
Reference NO. : KU13012943
Applicant Name: LALITA PATGAR
Address : W/o Mahadev Patgar, M Anand Rao
Exension,milagatta, Shivamogga, Shimoga, 577201, Karnataka
Course Subject Fee
MA KANNADA Rs.5150/-
Fee Paid : Full Fee
Amount In Words : Five Thousand One Hundred Fifty Only
PAID TO THE CREDIT OF FINANCE OFFICER, KUVEMPU UNIVERSITY, SHANKARAGHATTA, SHIMOGA
(D), KARNATAKA
A/C NO :64100999567 WITH SBM,JNANASAHYADRI SHANKARAGHATTA SHIMOGA
Particulars Course Fee Bank Charges Total
Amount Rs.5150/- Rs.50/- Rs.5200/-
Amount In Words :Five Thousand Two Hundred Only
Date : Signature of the Remitter
Received Rupees
Date & Seal Signature of the Receiver
1. Accepted at all the branches of SBM
2. Collecting Branch has to enter Reference No : & Name of the
Candidate for this transaction in core Banking System
3. Not Transferable.
KUVEMPU UNIVERSITY
DIRECTORATE OF DISTANCE EDUCATION
Jnana Sahyadri, Shankaraghatta-577451, Shimoga(D),
Karnataka
CHALLAN
Student Copy - To be retained with applicant
S.B.M POWER JYOTHY A/C NO. :64100999567
STATE BANK OF MYSORE, JNANASAHYADRI BRANCH
BRANCH CODE : 40759 IFSC CODE : SBMY0040759
BANK USE ONLY
Bank STATE BANK OF MYSORE
Branch Name
Branch Code
Journal NO.
Date
Reference NO. : KU13012943
Applicant Name: LALITA PATGAR
Address : W/o Mahadev Patgar, M Anand Rao
Exension,milagatta, Shivamogga, Shimoga, 577201, Karnataka
Course Subject Fee
MA KANNADA Rs.5150/-
Fee Paid : Full Fee
Amount In Words : Five Thousand One Hundred Fifty Only
PAID TO THE CREDIT OF FINANCE OFFICER, KUVEMPU UNIVERSITY, SHANKARAGHATTA, SHIMOGA (D),
KARNATAKA
A/C NO :64100999567 WITH SBM,JNANASAHYADRI SHANKARAGHATTA SHIMOGA
Particulars Course Fee Bank Charges Total
Amount Rs.5150/- Rs.50/- Rs.5200/-
Amount In Words :Five Thousand Two Hundred Only
Date : Signature of the Remitter
Received Rupees
Date & Seal Signature of the Receiver
1. Accepted at all the branches of SBM
2. Collecting Branch has to enter Reference No : & Name of the
Candidate for this transaction in core Banking System
3. Not Transferable.
