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GOVERNMENT OF KARNATAKA
DEPARTMENT OF TECHNICAL EDUCATION
BOARD OF TECHNICAL EXAMINATIONS
Application for* ……………….20….Semester Diploma Examinations (* Write month of Exam)
(To be filled in by the Candidate)
01. Institution Code
02 Name of the Institution………………………………………………...............................
03. Course Name & Code: ……………………………………………………………………
04. Name of the candidate (in block
Letters)
05. Father’s Name
06. Mother’s Name
(The above Names should be
as per S.S.L.C. Marks Card and Space
should be left for initials & surname)
07. Sex (Write B for Boy G for Girl)
08. Religion
Religion Hindu Muslim Christian Buddist Jain Sikh Parsis Anglo
Indian
Others
Code 1 2 3 4 5 6 7 8 9
09. Category
Category SC ST Cat-I IIA IIB IIIA IIIB GEN
Code 1 2 3 4 5 6 7 8
10. Write PH for Physically Handicapped otherwise write “NO”
11. Write R for Rural and U for Urban
12. Native District (Refer District Code)
13. District in which Candidate is studying at present (Refer District Code)
14. SSLC or Equivalent examination passed
(if Karnataka SSLC write 1
if equivalent exam in Karnataka write 2
if non-Karnataka SSLC equivalent write 3)
15. Diploma Register No.
16. a) Are you regular student in current semester? YES
b) If “YES” Give full exam details of current Semester.
SEM Subject Codes (To be filled by Student) Fees (Office Use)
01 02 03 04 05 06 07 08
c) Part Exam: Give details of failed subjects in previous semesters, if any.
Semester Subject Codes (To be filled by Student) Fees (Office Use)**
01 02 03 04 05 06 07
I
II
III
IV
V
VI
**Fees to be calculated semester wise. If more than two subjects in any semester collect full fees.
17. For I T I Lateral Entry Scheme student:
Sem
Bridge Subject Codes (To be filled by
Student) Fees (Office Use)
01 02
III
IV
18. External: If the candidate registered as an External Candidate write “Y” otherwise “N”.
Certified that the information furnished by me is correct to the best of my knowledge and
attested copies of marks cards & Income certificate (if any) are enclosed herewith.
Mob.No.
Date: Signature of Candidate.
Place:
(For Office Use Only)
Certified that the information furnished by the candidate is verified by me and found correct.
Date: Signature of the Head of Section
Place:
(a) Total Fees Paid : Rs
(b) Receipt No.& Date :
(c) Serial No. in the Consolidated List
(d) Scrutinised by : Initials of the case worker:
Initials of the Suptd. / Registrar
Date: SIGNATURE OF THE PRINCIPAL.
Place:
NO
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