Candidate's Details

Application Number : 555555

1 Course/s Applied for PGCET : M.Tech/M Arch (only)FullTime
CANDIDATE'S PHOTO
2 Name of the Candidate : SAMPLE
3 Name of the Father : FATHER
4 Name of the Mother : MOTHER
5 Date of Birth : 22:02:2000
6 Gender : Male 7 Quota : Karnataka
8. Marital Status Single Spouse Name

9. Annual Income of the family from All Sources (If married include your spouse 1000000
income also)
10 Category : General Merit 10 a. Sub-Caste : SUBCASTE
Income RD Number (RD00-------)
Caste RD Number starting with (RD0--------)

11 Religion : Hindu
12 Eligibility Clause Code: a
13 Qualifying Degree / Engineering Branch ? B.E - COMPUTER SCIENCE ENGG

Study Information
Have You done BCA, BSc (I.T / Computer Science ) with Mathmatics at 10+2 level or at Yes
Graduate Level ? (for Lateral entry to 2nd Year MCA )
Qualifying Degree Status ? Completed University Seat No : (USN) 12345
Qualifying Degree College Name : DEGREE Qualifying Degree University VITU
Name :
Total Number of Years of Study in Karnataka : 12
Particulars of Result Month of Passing Year of Passing Maximum Marks Secured Marks
Examination
1 Pass April 2015 500 450

2 Pass April 2016 500 450

3 Pass April 2017 500 450

4 Pass April 2018 500 450

5 Pass April 2019 500 450

14 Do You Claim Reservation Under Physically Disabled Quota ? No

15 Do You Claim Reservation Under Ex-Serviceman Quota ? No
16 Do You Claim Reservation Under 371(J) (Hyderabad Karnataka) Quota ? No
16 (a) 371(J) RD Number starting with (RD0--------)

M.Tech Program Details (Only for M.tech Candidates)

PGCET Appearing under : TYPE A

PGCET Exam Appearing Course Name : Computer Science Eng

Have you Appeared for GATE during 2018 or 2019 ? No

GATE Code :

GATE Score : 0

Do You Claim Seat under Sponsered Quota? No

17. PGCET Examination Centre BELGAUM (BELAGAVI)

Candidate's Postal Address for Communication

Address : 12345,BANGALORE,HOSKOTE,BANGALORE URBAN (BENGALURU),KARNATAKA-123456
Mobile No : 9999999999
Email : email@gmail.com

Declaration
 I declare that the above information is true and correct to the best of my knowledge and belief. I have gone through the
relevant Government Orders, Admission Rules and all Notifications / Website Notification issued by competent Authorityfor
PGCET-2019 and understand the same.If any of the information furnished above is found to be false or incorrect, I shall
automatically forfeit my claim to be considered for a seat or the seat already been opted by me in a Professional College in
Karnataka. In such event, I will also liable for such civil and criminal action as the State Government / KEA may take against me
in this regard.

Signature of the Left Hand Thumb impression of Date:

Candidate the Candidate

Principal / Gazetted Officer Signature

Name:
Signature:

Seal:

PAYMENT STATUS
Appno : NAME OF THE CANDIDATE :
APPLICATION FEES : BANK NAME :
BANK CHARGES : BANK Ref NUMBER :

Printed Date