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KHALLIKOTE AUTONOMOUS COLLEGE, BERHAMPUR, GANJAM KAC

APPLICATION FORM FOR UG EXAMINATION - 1st Semester (Back/Improvment)

Khallikote Autonomous College UG

COLLEGE NAME: Khallikote Autonomous College

EXAM ROLL NO: 011603CM399
REGISTRATION DATE: 23-12-2018
CLASS ROLL: BC16-087
STREAM: COMMERCE
REGD. NO:
CORE: Commerce
STUDENT NAME: A BALAKRISHNA REDDY
SEMESTER: 1st Semester Back/Improvment
MOTHER'S NAME: A INDUMATI REDDY
MOBILE NO: 9040815345
FATHER'S NAME: A RAMARAO REDDY
EMAIL ID: abreddy2017@gmail.com
ADDRESS FOR CORRESPONDENCE
At/Po: ANKULI
SUBJECTS DETAILS City: BERHAMPUR
Dist: GANJAM
CORE-02: COMMERCE-P02 State: Odisha
Pin: 760010
Country: India

Declaration: I do hereby declare that the particulars given above are true to the best of my knowledge and belief.

Certified that Full Signature of the Candidate

1. The particulars given by the candidate are correct.

2. I have verified his/her certificates in original of the qualifying examination and the registration slip.
3. His/her conduct has been good and has studied diligently.
4. He/she has the required percentage of attandence and the candidate qualifies for the examination as per the regulation.
5. I know nothing against his/her moral character.

Signature of Verifying Officer Signature of Head Signature of the Principal

INSTRUCTIONS

1. No application shall be entertained unless it is properly filled in and submitted along with necessary documents in conformity with the regulations
and instructions of the university/college as amended from time to time.
2. No candidate shall be allowed to offer any subject or paper other than those mentioned in this application provided the candidate is eligible under
the Regulation to offer such subject or paper.
3. No application for admission to the examination shall be entertained after the due date.In exceptional cases permission may be granted provided the
reason fir delay is considered to be sufficent and reasonable and the application along with the requisite fee(Tatkal mode) must reache the office on
or before seven days of commencement of the examination .
4. Application forms duly not filled in will be rejected at any stage of detection.
5. The candidate is responsible for the address and phone no provided for all future correspondance regarding the exam.

Please Tick The Fee Which is Applicable

1.Examination fee 280 5.Squad fee 100 9.Computer Laboratory Fee 50
2.Central Valuation fee 150 6.fee for Mark sheet 50 10.Late fee 100
3.Center Charge 100 7.Fee for Provisional Certificate 0 11.Tatkal seva 1000
4.Registration fee 50 8.Laboratory fee for practicals 50 TOTAL:

FOR CASH COUNTER

Amount collected Rs :
Rupees:

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Khallikote University, Berhampur | e-Form FillUp System http://sbrgwomenscollege.org/UG1STBACK2016/print.php

Reciept No: Date:

Dealing
Assistant

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