SRINIVAS UNIVERSITY

SRINIVAS
UNIVERSITY

(A State Private University, established by Act 42/2013 of Karnataka Legislative Assembly) (Under Section 22 of UGC Act)
Administrative Office : G.H.S. ROAD, MANGALURU - 575 001, KARNATAKA, INDIA
Phone No.’s : 0824 - 2425966, 2421566, 2412382, 2444891 Fax No. : (0824) - 2442766
E-mail : [email protected] Website: www.srinivasuniversity.edu.in
SAMAGRA GNANA
(ONLY SUBJECT TO COURTS/JUDICIAL FORUMS AT MANGALURU, D.K)

Application No. APPLICATION FORM

FOR ADMISSION PHOTOGRAPH
ACADEMIC YEAR Paste your recent size
photograph not older
20__ - 20__ than three months

NAME OF THE APPLICANT (IN CAPITAL LETTERS) ( AS PER THE “X” CERTIFICATE)

DATE OF BIRTH SEX (TICK ONE) CASTE(GEN./SC/ST/OBC) RELIGION BLOODGROUP

DATE MONTH YEAR MALE FEMALE

STATUS : GENERAL/ NRI/ FOREIGN NATIONAL COUNTRY OF PERMANENT RESIDENCE STATE OF DOMICILE

MOTHER TONGUE PLACE OF BIRTH NATIONALITY

FATHER’S NAME OCCUPATION ANNUAL INCOME

MOTHER’S NAME OCCUPATION ANNUAL INCOME

FATHER’S MOBILE NUMBER FATHER’S E-MAIL ID:

MOTHER’S MOBILE NUMBER MOTHER’S E-MAIL ID:

STUDENT’S MOBILE NUMBER STUDENT’S E-MAIL ID:

GUARDIAN’S MOBILE NUMBER GUARDIAN’S NAME (if parent’s is not alive)

PARENT’S LAND LINE NUMBER STUDENT AADHAR NUMBER

PERMANENT POSTAL ADDRESS :-

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.......................................................................................................................................................................City .....................................................

District.....................................................................State ....................................................................................Pincode.....................................
 COURSE PREFERRED (PUT üMARKS)
1. BBA* 2. BCA* 3. B.Com* 4. BA* 5. B.Sc.Nursing
6. B.Sc.* 7. BPT 8. DPT 9. BHMCT 10. B.Sc.(Allied)*
11. B.S.W 12. B.Tech* 13. II B.Tech* 14. B.Sc.(HM) 15. II B.Sc.(Allied)*
16. B.Sc.(ID) 17. B.Sc.(F.S)* 18. B.Des-UX 19. B.Ed 20. M.Sc.(Allied)*
21. MBA* 22. MCA* 23. M.Com* 24. M.A* 25. M.Sc.(F.S)*
26. M.Sc* 27. MPT* 28. M.Tech* 29. MSW* 30. M.Des-UX
31. 32. 33. 34. 35.

COURSE DETAIL: __________________________________

* Specialisation if any (please specify) Signature of the Applicant
PAN & AADHAR NUMBER : (To be filled Compulsorily)
FATHER’S MOTHER’S
PAN PAN

AADHAR AADHAR

ACADEMIC INFORMATION :
Examination Name of the Institute Lo ca ti on Year of Class
Su bjec ts Boa rd/Un ivers ity
Pas s in g and %

S.S.L.C/
E qu iv al en t

P.U.C/
E qu iv al en t

Degree/
E qu iv al en t

DECLARATION BY THE CANDIDATE

I,Mr./Ms...............................................................................S/o./D/o...........................................................................
have carefully read and fully understood the details given in the prospectus for admission. I hereby fully agree
to the terms and conditions set by the institution and declare that,
(i) The information furnished by me is correct and complete in all respects and if at any time the information/
Certificate submitted by me is found to be false, the seat allotted to me will be summarily cancelled and I will
be liable for criminal prosecution.
(ii) In all matters regarding my admission to the course, the decision of the Principal is final and binding on me.
(iii) I shall abide by the college and hostel rules and regulations in force and as amended from time to time.
(iv) I will do nothing unworthy of a student of the college either inside or outside the college/hostel campus.
(v) The Principal has the full authority to expel me for disinterest in studies, misbehaviour and continuous failure in
attending class or examinations.
(vi) I will strictly follow the dress code/uniform prescribed by the college. In the interest of discipline and
decorum I myself undertake not to wear indecent, unethical, non-acceptable dresses. Further, I understand & I
comply with the requirements of the college and no dress which is reflecting my political or religious belief or
inclination will be a part of my dress in the campus.
(vii) I am fully aware of the law regarding prohibition of ragging and the punishments therein. If I indulge in any
action which can be defined as ragging under the law or possessing and using cell phone or any other legally
banned items, I will be liable for fine/suspension/dismissal prosecution as per law including the impounding of
cell phone and other banned items found in my possession.
(viii) No part of the fees paid under any head will be refunded at any point of time and for whatever reasons, if I
choose to discontinue my course at any time after admission, I am liable and bind myself to pay the full fee of
the entire course to which I was admitted.
(ix) The admisison is subject to the approval/eligibility criteria as prescribed by the regulations of Srinivas
University and I undertake to fully comply with its requirements.
(x) I also undertake to pay the fees and other dues of the Institution/recognised bodies promptly and regularly
and/or on demand.
(xi) Once I join a course, any change over to other course is not permissible.
(xii) Once I join the hostel I will continue till the end of the academic year.
(xiii) Principal/Warden has all rights to allocate/shift to any of the hostel room/building at any point of time as per the
decision of the appropriate authority.
(xiv) I abide by all the hostel rules and also bind myself not to disturb other inmates in the hostel.
(xv) I am liable to be sent out of the hostel for act of indiscipline or when the hostel/ mess dues is not paid in time/
or when demanded.
(xvi) Any disputes arising in respect of my admission or any other matter shall be only decided at the discretion of
the management and will be subject to the jurisdiction of courts/Consumer Redressal Forum/Authorities
at Mangaluru only. Any outside authority will not have the restriction over any of the above matters.

Place :
SIGNATURE OF THE APPLICANT
Date :
DECLARATION BY THE PARENT/LEGAL GUARDIAN

I,............................................................................S/o./D/o...............................................................................
Address:-...........................................................................................................................................................
....................................................................................do hereby state that, I have also read and understood

the above declaration made by my son/daughter/ward Mr./Ms........................................................................

Further I also state that:-
(i) I have read and agree for the above terms and conditions and I assure to co-operate with the college
authorities and assure the progress and good behaviour of my son/daughter/ward.
(ii) I am aware that, my son/daughter/ward will be subjected to the punishment stated above for ragging
or unauthorisely bringing the cell phone to the college campus.
(iii) I assure that I will call on college, Principal and faculty members as frequently as possible to discuss
the attitude and progress of my son/daughter/ward.
(iv) I also assure to give all assistance and co-operation to Principal in all actions taken in the interest of the
students in general and cause of education and progess of my son/daughter/ward in particular.
(v) I under take that, my son/daughter/ward will strictly follow the dress code/uniform prescribed by the
college. In the interest of discipline and decorum I also undertake that, my son/daughter/ward will not
wear indecent, unethical, non-acceptable dresses. Further, I will comply with the requirements of the
college and no dress which is reflecting his/her political or religious belief or inclination will be a part
of his/her dress in the campus.
(vi) I am also aware that the college will not refund the fee either in full or in part, under any circumstance.
If my son/daughter/ward decides to discontinue the course at any time after joining, I hereby undertake
to pay the college fees and dues for the remaining duration of the course.
(vii) I also certify that the information provided by my son/daughter/ward is true and that if any information
furnished is found to be untrue, then my son/daughter/ward or /and I may be liable for criminal
prosecution.
(viii) Submission of false documents will also render the seat alloted to my son/daughter/ward invaild.

Place :
COUNTER SIGNATURE OF THE PARENT/
Date : LEGAL GUARDIAN (Mention relationship) P.T.O
 GUIDANCE NOTES :
v You should ensure that you have filled in all the required information correctly.
v Please ensure that you have submitted the following documents along with the form.

Attested copies of :
v 10th Standard marks card for proof of date of birth
v 12th Standard marks card
v Degree marks cards (PG Courses)
v TC / Conduct / Migration Certificate
v Student Aadhar Card Copy

Registration Fee of Rs.1000/- by Cash/DD favouring

“SRINIVAS UNIVERSITY”
payable at Mangaluru, Karnataka

The application form with all enclosures should be forwarded personally / through post ;
SRINIVAS UNIVERSITY
ADMINISTRATIVE OFFICE : G. H. S. ROAD, MANGALURU - 575 001
KARNATAKA, INDIA

FOR OFFICE USE ONLY

DATE :

NAME : COURSE :

FEES PAID DETAIL :

REGISTRATIONFEES :

Receiver’s Name & Signature