REGIONAL INSTITUTE OF EDUCATION, MYSORE 570006

[National Council of Educational Research and Training, New Delhi]

APPLICATION FORM FOR B.Sc.Ed. / B.A.Ed./M.Ed.

Affix Stamp Size
(Last date for Receipt of filled in Application : 20.06.2011) Photograph

FOR OFFICE USE

No. Acad/2011-12 Reg. No. -------------------------- Home State -----------------------

1. Please put a tick mark (
) only in the box against the course for which you are applying for admission.

1. B.Sc.Ed. PCM 2. B.A.Ed. 3. M.Ed.

CBZ

2. Name : (Write as recorded in the class X pass certificate in Capital letters)

3. Sex : Male Female 4. Date of Birth:

4. Category : General SC ST OBC Phy. Handicapped

5. Name & Address of the Institution from where qualifying examination passed:

-----------------------------------------------------------------------------------------------------------------------------

6. Whether employed : Yes No

If the answer is ‘Yes’ attach ‘No Objection Certificate’ from the employer.

7. Father’s/ Mother’s / Spouse’s Name : -----------------------------------------------------------------------------

8. Address for Correspondence: 10. Permanent Address:

----------------------------------------------------------- ----------------------------------------------------------------

----------------------------------------------------------- ----------------------------------------------------------------

----------------------------------------------------------- ----------------------------------------------------------------

----------------------------------------------------------- ----------------------------------------------------------------

State :-------------------------Pincode --------------- State :-------------------------------Pincode ---------------

Contact Phone No. (with code) ------------------- Contact Phone No. (with code) -------------------------

E-mail I.D. -------------------------------------------- E-mail I.D. ------------------------------------------------

9. D.D.No. ------------------------------------------- Date --------------------

….2
10. Qualifying Examination :

Programme B.Sc.Ed. B.A.Ed. M.Ed.

Qualifying Exam PUC or PUC B.Ed. B.Sc.Ed. / M.A./M.Sc./
equivalent B.A.Ed. M.Com
(Marks of
Education
subjects only)

Name of University/
Board

Grand Total Marks

for all subjects

Total Marks Secured

% of Marks secured

Subjects studied

Declaration

I hereby declare that the information furnished in this application is true and accurate. I understand that any
wrong or incomplete information will disqualify me for admission.

Place :
Date : Signature of Father / Mother / Guardian Signature of Applicant

Documents to be attached with the Application Form :

1. Attested Copy of Class X Examination Pass certificate, 2. Caste Certificate (for SC/ST/OBC applicants only), 3. Physically
Handicapped Certificate (for Physically Handicapped applicants only), 4. Qualifying Examination Mark sheets, 5. Domicile /
Community / Nativity Certificate. 6. A self-addressed (26 cm × 12 cm) size envelope bearing Rs.10/- postal stamp. Along with
each downloaded application, an Account Payee Demand Draft for Rs.300/- (in case of SC/ST candidates, Rs.250/-)
should be sent.

Application duly filled in and complete in all respects with all documents should reach the Asst. Programme
Coordinator, Academic Section, Regional Institute of Education, Mysore 570 006 on or before
20.6.2011.
 REGIONAL INSTITUTE OF EDUCATION, MYSORE 570 006

ADMISSION TICKET

Affix
Stamp size
photo duly
attested by
Programme Applied : Gazetted

Name of the Candidate :

State :

Centre for Entrance Test :

Date : Signature of Applicant

Note : Candidates have to bring Admission Ticket for Entrance Test duly attested by a Gazetted Officer.