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Candidate Details

Application Number 147576

1. Name of the Candidate : ARCHANA BHARGAVI
2. Name of the Mother : LALITHA
3. Name of the Father : HARISHANKAR

4. Date Of Birth: 10-07-1998 5. Gender: Female

6. Candidate Contact Mobile 8050833359 7. E-Mail-ID : VANDANAPUBLICATIO
Number : N@GMAIL.COM
8. Mother Tongue : HINDI 9. Annual Income of the 80000
(As per school/college Family from all Sources :
record)
10. Religion : Hindu 11. Nationality : Indian
12. Reservation Category : Category-2A 13. Name of the Caste : MALI
13 a. Caste / Category / Income Certificate (Acknowledgement No..start with RD----) 0038082024696
14. Eligibility Clause Code : a
15. Place where you wish to appear for CET-2016 ? BENGALURU (BANGALORE)
16. Examination Details
Qualifying Examination : Karnataka 2nd PU
Mention the University / Board Name :
a. If CBSE / CISCE School Name :
b. Are you appearing for Karnataka 2nd PUC Annual Examination 2016 ? Yes
c. If No enter the year of passing :
d. PUC Student Number : 2015AN1790380
Study Information
17. Total Number of completed years of study in Karnataka (From 1st to 12th std.): 12
18. Have you studied in Rural area in Karnataka from 1st to 10th standard ? No
19. Have you studied in Kannada Medium from 1st to 10th standard ? No
20. Are you claiming reservation under Article 371(J) Hyderabad Karnataka ? No
21.Candidate's Postal Address for Communication
Address : NO 14 4THBLOCK 1STCROSS NEAR RR HIGH SCHOOL, NEXT TO LOKESH BUILDING D
BSANDRA, BANGALORE, , , KARNATAKA - 560097
STD Code : Phone Number : 8050833359
Qualifying Examination Details
22. Have you studied SSLC/10th standard in Karnataka? Yes
23. State where appeared for KARNATAKA 24. 2nd PUC District BENGALURU URBAN
2nd PUC/12th/Equivalent ? (If Karnataka):
25. Native State : UTTAR PRADESH 25 a. Native District
(If Karnataka):
26. Are you a Son/Daughter of Jammu & Kashmiri Migrant ? No
27. Special Category:
28. Are you claiming Agriculturist Quota Reservation? No
a. Agriculture Practical Exam Centre:
29.Details of Appearing Previous CET Exams
Have you appeared for previous CET Exam ? No
CET NO:
Mention the year of appearance:

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Have you obtained any seat in CET and taken Admission to college ?
Study Details
Complete Name & Address of theSchool / College Classes Year of Year of Year of
with Telephone Number studied study From study To Passing
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 1 2004 2005 2005
PHONE 08022195603
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 2 2005 2006 2006
PHONE 08022195603
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 3 2006 2007 2007
PHONE 08022195603
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 4 2007 2008 2008
PHONE 08022195603
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 5 2008 2009 2009
PHONE 08022195603
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 6 2009 2010 2010
PHONE 08022195603
BEL PRIMARY SCHOOL JALAHALLI BANGALORE 7 2010 2011 2011
PHONE 08022195603
VISHWA BHARATI HIGH SCHOOL RAMACHANDRAPURA 8 2011 2012 2012
JALAHALLI BANGALORE 13
PHONE 23455202
VISHWA BHARATI HIGH SCHOOL RAMACHANDRAPURA 9 2012 2013 2013
JALAHALLI BANGALORE 13
PHONE 23455202
VISHWA BHARATI HIGH SCHOOL RAMACHANDRAPURA 10 2013 2014 2014
JALAHALLI BANGALORE 13
PHONE 23455202
Declaration
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.

Signature of the Left Hand Thumb Signature of the

Parent / Guardian impression of the Candidate
Candidate
Date: 20-01-2016 16:14:12
Principal / Gazetted Officer Signature
Name:
Signature:
Seal:

Payment Status
Application Number: Name of the
Candidate:
Application Fees: Bank/Post Office
Name:
Bank/PO Charges: Bank/Post Office Ref
Number:
Total Amount: Date of Payment:

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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: 20-01-2016 04-20-09