IIPR INDIAN INSTITUTE OF PSYCHOLOGY & RESEARCH Affiliated to Bangalore University & Approved by Government of Karnataka Application to Post Graduate Courses For office use only Application No.: Date of Submission: Tick the course applying for: Photo M.Sc. Psychology M.Sc. Psychological Counseling 1. Name of the Applicant (in Block Letters as in Degree Certificate) 2. Date of Birth Gender: Male Day 3. Month Contact Numbers (Land line with STD Code and Mobile Number) 4. Email ID 5. 6. Place of Birth (City, District, State & Nationality) Passport Number with Validity period (if available) 7. Permanent Address (with PIN code) 8. Address for Correspondence (with PIN code) 9. Local Guardian’s Address (Address with Phone Number) 10. Father’s Name Occupation Telephone / Mobile No. Email ID 11. Mother’s Name Occupation Telephone / Mobile No. Email ID Year Female 12. Blood Group 13. Religion 14. Caste 15. Karnataka (7 Years Study in Karnataka)/ Non Karnataka (Studied in other States) 16. Reservation Category: General III B SC ST OBC Cat – II A Cat-I Cat – II B III A Any Other specify........................................... 17. Academic Record a. Details of Qualifying Examinations: Name of the Degree Name of the University Registration No. / College/ Board Overall Percentage of Marks Year / Month of Passing 10th/ SSLC/ Equivalent 12th/ PUC/ Equivalent BA/ B.Sc./ BA(Honrs.) Others......... b. Details of Marks in the Undergraduate Course: Subject Mark Max Psychology Obtional Subjects 1. Scored Max Scored Max 2. Scored Max 3. 4.Language 1 Specify________ 5. Language 2 Specify________ Scored Max Scored Max Score 1Sem / 1Year 2Sem / 2Year 3Sem / 3Year 4Sem / 4Year 5Sem / 5Year 6Sem / 6Year Aggregate Total Percentage (%) 18. Details of any other PG Degree / Diploma / Certification Course obtained or being obtained ................................................................................................................................................................. ................................................................................................................................................................. ... 19. Name, designation and addresses of two competent persons who could be contacted for reference check 1. Name................................................ Address............................................ .......................................................... .......................................................... Phone No........................................ Email................................................. 2. Name................................................ Address............................................ .......................................................... .......................................................... Phone No......................................... Email................................................. 20. Application Fee Payment Details Payment is made by Cash DD (Tick Appropriate) Amount _____________________ Date ______________ Name of the Bank__________________ Branch ____________________________________ DD No. ______________________________ For cash payment, Cash Receipt No. __________________________________________________ Declaration 21. 1) I hereby declare that information mentioned in the application is true to the best of my knowledge. 2) I agree to abide by the rules and regulations of the Institute in force from time to time if admitted. 3) I am aware that my admission is subject to the approval of Bangalore University. 4) I undertake to intimate the Institute immediately if there is / are any change/s in my permanent address, correspondence address, Email ID, Phone No. with STD code, Mobile No. etc., Date: Place: Signature of the Applicant Signature of Parent / Guardian (Incomplete Application / Application without mandatory enclosures is liable to be rejected) 22. Write in about 100 words the reasons for applying for this course. Use the space provided below. Guidelines for Submission of Application Forms: Details of the timeline of admission process are available on the IIPR website www.iipr.in Application forms should be filled up neatly in block letters. Application forms along with supporting documents may be submitted directly (In-Person) between 10 AM and 5 PM on all working days at the office of admissions or could be sent through registered post, courier service or could be handed over in person at the below mentioned addressOffice of Admissions, IIPR, St. Anthony’s Friary, # 85, Hosur Road, Bangalore- 560095. Following enclosures need to be submitted along with the duly filled in application forms.1. A Demand Draft (DD) for INR 1000 should be attached, drawn in favour of “IIPR” payable at “Bangalore”. Name of the Applicant and Course Applied for should be written behind the DD. If any candidate prefers to opt for online entrance exam and online interview then the DD drawn should be for Rs. 2500/-. 2. Copy of 10th and Copy of PUC/12th/10+2 Marks Sheets. 3. Copy of Degree Certificate and Marks Sheets of all semesters / years of the qualifying examination for postgraduate courses. 4. Conduct certificate from the principal of the college / university department last attended / from a Gazetted officer 5. Copy of Transfer Certificate (if available) 6. Copy of Migration Certificate for candidates from outside Bangalore University (if available)