Final Copy [667de35c04db834eec2d4e478aef784f]

UG NEET 2019
REGISTRATION - 1

5Ŗ¬ltŖ4ĝOnline Application Form - Student Information

Application Number 459312

4YÍħ[²lc\h
Candidate Name ) : N PRAVALIKA SWAMY

Ÿeĵ[²lc\h
Mother Name ) : B JAMUNA

Q2¡l[²lc\h
Father Name ) : N C NARAYANASWAMY

dhġ¾SĨ£e2B(Date of birth): 17-09-2000

Ĺ2D(Gender) : Female

4YÍħ[c2VBSū¦ltşc2‘lÍ 9740614835 6ijsşĻ­ecE-Mail-Id : drncnswamy@gmail.com

Candidate Contact Mobile Number :
4YÍħ[c2VBS42•lĻ­ecCandidate's Postal Address for Communication

Ļ­ec NARASAPURA VILLAGE AND POST, KOLAR TALUK, KOLAR, KOLAR, KOLAR, KARNATAKA -
563133
Address :
įsŖU2Xŝ 7892115560
Phone Number :
Ŀ2ĨU`bD_ľ6ġVĸsďeĻ`\Details of Appearing Previous CET Exams

Īs`ƒĿ2ĨU`bD_ĹÐľ6ġVĸsďl[UhÇŸl’lShli2ģĨÅsªe?Have you appeared for previous CET Exam Yes

or NEET Exam ?
ľ6ġc2‘lÍCET NO : SL024

Vĸsďl[UhÇŸl’lShli2N`bYear of appearance : 2018

ľ6ġ[ĹÐĪs`ƒ©e`ƒ¡eS\hľsLUhÇŸl’lShliģĨÅsªeZQhÐe¬lsĝ’lVήlsaVœlĨĨÅsªe! No
Have you obtained any seat in CET and taken Admission to college ?
Reservation Details
11Īs`ƒB£eLBƮlisšeƮS4ģ[ĹÐ4ĝcĹÐchĦÃĨÅsĸ! Karnataka
Are you Applying under the karnataka quota?
TZReligion : Hindu ªeĽĄs[ŸlNationality : Indian

¨eQj§e°l
ci´şe¬lsŊªleŏVΐe\ Kannada
Mother Tongue
Are you claiming Religious Minority Quota ? No
(only medical and dental )
Are you claiming Linguistic Minority Quota ? No
(only medical and dental )
—eĦ[²lc\hName of the Caste : ADI KARNATAKA

IJsc¬eĦ`DReservation Category : Scheduled Caste

NEET ROLL NUMBER : 270229858 NEET SCORE : 122

Caste RD Numbe RD0038697016416 Income RD Number RD0038697016417

BhLh2XS®eĽB`\¨eU<¬eÐZi^Dĺ2S\iD_ĹÐ 1190712
Annual Income of the family from all sources in Rupees
:
5ġBş371(J) ²ltSªe¦eŔB£eLBlisšeSģ[ĹÐIJsc¬eĦVœl[^h4dĸ\hĻªe! No
Are you claiming reservation under Article 371(J) Hyderabad Karnataka ?

Printed Date: 28-06-2019 02-17-54

 Final Copy [667de35c04db834eec2d4e478aef784f]
UG NEET 2019
REGISTRATION - 1

Īs`ƒĸ2S£lsQ\DĦ[`ªl’lB£eLBS’eÎIJsPVΡlsaSĹЮeÍc2D¨eģĨÅsªe! No
Have you studied in Rural area in Karnataka from 1st to 10th standard ?
Īs`ƒ1ĸ2S10£lsQ\DĦ[`ªl’lBUÇN¨eTÍZSĹЮeÍc2D¨eģĨÅsªe!8¬lÐsĕQceĸ5¡lsaS No
¨eĿĦ’eĖ
Have you studied in Kannada Medium from 1st to 10th standard in any
where India?
4dŸeB2ģllisŏ4UhÇ5Ķ´¨eģEligibility Clause Code : a

Ļ¯lsb`DSpecial Category :

42DĻB¬lŸl[ĻTNature of the handicap :

Īs`ƒIZh̐eļŮĸ`^±l’e\\ZDZD­l!Are you a Son/Daughter of Jammu & Kashmiri Migrant ? No

Are you ward of NRI ? No

VĸsďeĻ`\D_…Examination Details
4dŸeVĸsďlQualifying Examination : Karnataka 2nd PU Science

ĻaÒĻ¡eÍ^[¦lisŏ²lc\hMention the University / Board Name : -

B£eLBľİ<Ť6ľ><Ťľ65ĖSÅĹÐci´ş²lc\hIf Karnataka CBSE / CISCE School Name -

:
B£eLB£lsī[hľ
ĻĐeU\®eĽBVĸsďl’l²eIªeDhĻªe! No
Are you appearing for Karnataka 2nd PUC Annual Examination 2019 ?
ī[hci¾œl2ōc2‘lÍPUC Student Number : 2017MM1750232

6^ЮeSĹПlsDœl©eS`b`UhÇUZiĨľIf No Enter the Year of Passing : 2018

B£eLBSĹÐ
ĸ2S£lsQ\DĦ`ªl’l®eÍc2D¨eģŸlsDœl²li2ĨSV†P`bD_… 12
Total Number of completed years of study in Karnataka (From 1st to 12th std.):
Īs`ƒĸ2S£lsQ\DĦ[`ªl’lBUÇN¨eTÍZSĹЮeÍc2D¨eģĨÅsªe! No
Have you studied in Kannada Medium from 1st to 10th standard ?
Īs`ƒ<Ť<Ť<şľ£lsQ\DĦ[UhÇB£eLBSĹЮeÍc2D¨eģĨÅsªe! Yes
Have you studied SSLC/10th standard in Karnataka?
Īs`ƒ£lsī[hľ£lsQQÕ¨eUQ\DĦ[Vĸsďl[UhÇŸl’lShli2ģ\h`ªeIÍ KARNATAKA
State where appeared for 2nd PUC/12th/Equivalent :
Īs`ƒ£lsī[hľ£lsQQÕ¨eUQ\DĦ[Vĸsďl[UhÇŸl’lShli2ģ\h`ĝ¬lÐ KOLAR
District where appeared for 2nd PUC/12th/Equivalent exam :
cÄĺsBªeIÍNative State : KARNATAKA

cÄĺsBĝ¬lÐNative District : KOLAR

®eÍc2DĻ`\D_…£lsQ\DĦĵ2Sī[hľ£lsQ\DĦ4dŸeVĸsďl[`ªl’l
STUDY DETAILS : From 1st standard to II PUC / 12th standard / Qualifying Examination
ci´şe¬lsĝUĻ­ecZQhÃSi\®eĥc2‘lÍ ®eÍc2DS ®eÍc2DS ®eÍc2DS ŸlsDœl©eS
Complete Name & Address of the School / College with Q\DĦD_… ¤eÎ\2ıB`b li£l[`b `b
Telephone Number
Classes Year of study Year of Year of
Studied From study To Passing

VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 1 2006 2007 2007

POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 2 2007 2008 2008
POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 3 2008 2009 2009
POST KOLAR TALUK

Printed Date: 28-06-2019 02-17-54

 Final Copy [667de35c04db834eec2d4e478aef784f]
UG NEET 2019
REGISTRATION - 1

VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 4 2009 2010 2010

POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 5 2010 2011 2011
POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 6 2011 2012 2012
POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 7 2012 2013 2013
POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 8 2013 2014 2014
POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 9 2014 2015 2015
POST KOLAR TALUK
VIDYA JYOTHI SCHOOL BASAVANTHA VILLAGE TAMAKA 10 2015 2016 2016
POST KOLAR TALUK
VIDYA JYOTHI PU COLLEGE BASAVANTHA VILLAGE 11 2016 2017 2017
TAMAKA POST KOLAR TALUK
VIDYA JYOTHI PU COLLEGE BASAVANTHA VILLAGE 12 2017 2018 2018
TAMAKA POST KOLAR TALUK
Declaration
75Ŗ¬ltŖZh‘e2Q\Īsģ\h`<¬eвlsĺlD_…¨eĿĦD_…UZ’lĦĺSZġ¾’lcQͲeDhĪC\®l2Sh7Zi^BęisĽchŸlÃs®l7
5Ŗ¬ltŖ4ĝQh2Xh`ƒSl´c2X2ĩľS2Ÿl¨eĿĦltīģ[ĹвeDhl6<®lř±ltōUĹÐĪsģ\h`<¬eШeĿĦciG£lD_UhÇQh2¦e
<G¹ĸlĵ2S@Ĩ\hŸlÃs®l?2Sh®ls­l£e`ƒ5Ŗ¬ltŖZh‘e2Q\Īsģ\h`©e`ƒ¡ls¨eĿĦ[hQVƒÈ4R®e4cQÍ®l2ShB2NhX2SĹÐ
£e`ƒľsLUhÇ5Ķ´¨eNh`ZQhÐl6<ĵ2SľsLUhÇd2ělVœl[h`dB´UhÇB­lShli_…ÑŸlÃs®l²eDhªeIÍce\B£eLBVĸsďe
¤eÎĩe\`ƒ7c2X2TUZÌĻ\hSÆŸl’lShli_ÑXdh¡eSeUiUhĸsĦ[BÎZDĺ’lXSÆ£eĖ\hŸlÃs®l
We declare that the information furnished through online is true and correct to the best of our knowledge and belief.
We have read the Instructions carefully hosted on the KEA website "Information Bulletin for Filling up of Online
Application". In case any of the information furnished online by us is found to be false or incorrect, we shall forfeit the claim
to be considered or a seat selected and allotted by KEA. We are also liable for civil and criminal action, that the State
Government or the KEA may take against us in this regard.

ŪsbB\V†PcĿ<N 4YÍħ[<Nlt²l¦lÊ\_Dh\hQh 4YÍħ[V†PcĿ

lt²l¦lÊ\_Dh\hQh Left Hand Thumb Signature of the
impression of the Candidate Candidate
Signature of the Parent
/ Guardian

Date: 28-06-2019 14:17:43

¤eÎ2ah¤e^\D—lšlŏ5ĬscŝcĿPrincipal / Gazetted Officer Signature

²lc\hName :

V†PcĿSignature :

ūd\hSeal:

ah^´c2¡e[Ļ`\Payment Status

4ĝc2‘lÍ 459312 4YÍħ[²lc\h N PRAVALIKA SWAMY

Application Number: Name of the Candidate:

4ĝah^´ 250 ¦eÍ2Ń642•lB•lsĸ²lc\h ICICI Bank

Application Fees: Bank/e-post office Name :
¦eÍ2Ń642•lB•lsĸah^´ 10 ¦eÍ2Ń642•lB•lsĸ8¬lÐsCc2‘lÍ 1018747592
Bank/e-Post office Bank/e-post office Ref No :
Charge

Printed Date: 28-06-2019 02-17-54

 Final Copy [667de35c04db834eec2d4e478aef784f]
UG NEET 2019
REGISTRATION - 1

?Lh¾ah^´ 250 ah^´c2¡e[Ĩ£e2B 13-02-2019

Total Amount: Date of Payment:
DZĪľ1<¬eÐVÎĔÎĶV†P’li2NU2Q\4YÍħ[h42ĦZVÎĦ[UhÇZhĨÎľli2Nh¡eC¬l
œeBhÍij2ōVĸļs^£lc2SYSĹÐ
BœeÀ[®eĖcĹÐc¦lsBh
2ľsLhd2ělVÎĔÎĶ[cZ[SĹÐ?SĖch`—eĦZQhÃ5¡e[VΨePVQÎ`ƒ5Ŗ¬ltŖ4ĝ[cZ[SĹÐUZiĨľS—eĦZQhÃ
5¡e[`ƒBœeÀ[®eĖ?2¡ls5Ė\¦lsBh42ĦZęisbžl[U2Q\©e`ƒ¡lse\PBi´—eĦ[ĹÐXS¬e`žl’l4`eaĻ\h`ƒĨ^Ð
NOTE : 1. After completion of all the process the candidates are required to take final print out of the Online Application Form
and submit the same during Document Verification.
2. The CASTE and INCOME certificate to be produced by candidates during seat selection process should have the
same CASTE and INCOME, as mentioned in this Application Form. No change in Caste / Category will be
permitted after the final declaration.

Printed Date: 28-06-2019 02-17-54