INDIAN INSTITUTE OF PSYCHOLOGY & RESEARCH

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)