Edited Incomplete Application APP No: 145791

5Ŗ¬ltŖ4ĝOnline Application Form

I.Student Information
4ĝc2‘lÍApplication Number 145791

I . 1. 4YÍħ[²lc\hCandidate Name : CHIRAG M R

4YÍħ[²lc\h

I . 2. Q2¡l[²lc\hFather Name : RAVIKUMAR

Q2¡l[²lc\h

I . 3. Ÿeĵ[²lc\hMother Name : BANUMATHI C S

Ÿeĵ[²lc\h

I . 4. dhġ¾SĨ£e2BDate of birth : 05-06-2002

I . 5. Ĺ2DGender : Male

I . 6. 4YÍħ[c2VBSū¦ltşc2‘lÍ XXXXXX2498 I . 7ªeĽĄs[Ÿl Indian

Candidate Contact Mobile Number : Nationality

I . 8. 6ijsşĻ­ecE-Mail-Id : chiraXXX

I . 9. 4YÍħ[c2VBS42•lĻ­ecCandidate's Postal Address for Communication

Ļ­ec 12TH WARD K R NAGAR TOWN, ESHWAR NAGAR , K R NAGARA TALUK,
KRISHNARAJANAGAR, MYSURU (MYSORE), KARNATAKA - 571602
Address :
9 (f) V©e[ū¦ltşc2‘lÍ XXXXXX1693
Alternative Mobile Number :
I . 10. Ŀ2ĨU`bD_ľ6ġVĸsďeĻ`\Details of Appearing Previous CET Exams
I . 10(a). Īs`ƒĿ2ĨU`bD_ĹÐCET / NEET / NATA Vĸsďl[UhÇŸl’lShli2ģĨÅsªe! No
Have you appeared for previous CET / NEET / NATA Exam ?
II Reservation Details
II. 1. 4dŸeB2ģllisŏ4UhÇ5Ķ´¨eģEligibility Clause Code : a

II . 2. TZReligion : Hindu

II . 3¨eQj§e°l
ci´şe¬lsŊªleŏVΐe\ KANNADA
Mother Tongue
II. 4. Īs`ƒ<Ť<Ť<şľ£lsQ\DĦ[UhÇB£eLBSĹЮeÍc2D¨eģĨÅsªe! Yes
Have you studied SSLC/10th standard in Karnataka?
II . 5Īs`ƒB£eLBSĹÐ12£ls¦lisŏVĸsďl[UhÇXªlĨĨÅsªeeĥľli2ģĨÅsªe Yes
Xªl[hĦÃĨÅsªe!
Did you write/appearing/attending Board Exam of 12th in Karnataka?
II. 6B£eLBSĹÐ
1ĸ2S12£lsQ\DĦ`ªl’l®eÍc2D¨eģŸlsDœl²li2ĨSV†P 12
`bD_…
Total number of completed years of study in Karnataka (From 1st to 12th Std.)
II. 7Īs`ƒ¢eIJB4^Èc2‘eÍQIJsc¬eĦX[chĦÃsªe! No
Are you claiming Religious Minority Quota ?

®ltSÍĔs[ZQhÃS2Q®ltSÍĔs[lisŤDĺ’l¨eQÎZhľÐ2ZQhÃĔÎļ¹[Ŗ
only for medical and dental courses (Muslim /Christian)

Printed Date: 22-05-2020 05-29-08 Page No: 1

 Edited Incomplete Application APP No: 145791

II. 8. Are you claiming Linguistic Minority Quota ? No

®ltSÍĔs[ZQhÃS2Q®ltSÍĔs[lisŤDĺ’l¨eQÎ
only for medical and dental courses (Tulu/Tamil/Telugu/Kodava)
6ShĪs`ƒUZiĨľ\h`¨eQj§e°lB£eLBSĹЮeÍc2D¨eģS`bD_…104R®e12
£lsQ\DĦ[¦lisŏVĸsďl²eDieÐŤlisŏijs¬l4`^2İQ®eĖ\hQál
Note : It depends on Mother Tounge ,Number of years study in Karnataka ,
Board Exam of 10th/12th/Both in Karnataka. and clause code 'a'
II . 9. —eĦ[²lc\hName of the Caste : VEERASHAIVALINGAYATHA

II . 9.(a). Īs`ƒ5Ķ´¨eģ\h`IJsc¬eĦ`D Category-3B

Reservation category you have selected :
II . 9.(b). Caste Certificate RD Number
II . 9.(c). Income Certificate RD Number RD0038721084060

II. 10BhLh2XS®eĽB`\¨eU<¬eÐZi^Dĺ2S\iD_ĹÐ 506340

Annual Income of the family from all sources in Rupees :
II. 11. 5ġBş371(J) ²ltSªe¦eŔB£eLBlisšeSģ[ĹÐIJsc¬eĦVœl[^h4dĸ\hĻªe! No
Are you claiming reservation under Article 371(J) Hyderabad Karnataka ?
II . 12. Īs`ƒĸ2S£lsQ\DĦ[`ªl’lB£eLBS’eÎIJsPVΡlsaSĹЮeÍc2D¨eģĨÅsªe! No
Have you studied in Rural area of Karnataka from 1st to 10th standard ?
II . 13. Īs`ƒĸ2S£lsQ\DĦ[`ªl’lBUÇN¨eTÍZSĹЮeÍc2D¨eģĨÅsªe! No
Have you studied in Kannada Medium from 1st to 10th standard ?
II. 14. Ļ¯lsbIJsc¬eĦ`DSpecial Category Reservation :

II. 15Īs`ƒ2020\±e¨eUÍVήlsaVĸsďlXªl[^h6ěºch`cÄ_5Ķ´¨eģ KRISHNARAJANAGAR

Select the preference place one you wish to appear for CET-2020
Select the preference place two you wish to appear for CET-2020

Select the preference place three you wish to appear for CET-2020

II. 16. Īs`ƒIZh̐eļŮĸ`^±l’e\\ZDZD­l!Are you a Son/Daughter of Jammu & No

Kashmiri Migrant ?

II.17. VĸsďeĻ`\D_…Examination Details

II.17(a). 4dŸeVĸsďlQualifying Examination Board: Karnataka 2nd PU Science

II.17(b). ĻaÒĻ¡eÍ^[¦lisŏ²lc\hMention the University / Board Name :

II.17(d). B£eLBľİ<Ť6ľ><Ťľ65ĖSÅĹÐci´ş²lc\hIf Karnataka CBSE / CISCE

School Name :
II.17(e). B£eLB£lsī[hľ
ĻĐeU\®eĽBVĸsďl’l²eIªeDhĻªe! Yes
Are you appearing for Karnataka 2nd PUC Annual Examination 2020 (Science) ?
II.17(f). ī[hci¾œl2ōc2‘lÍPUC Student Number : 2019NN3520061

II.17(g). 6^ЮeSĹПlsDœl©eS`b`UhÇUZiĨľIf No Enter the Year of Passing :

II.17(i). Īs`ƒ£lsī[hľ£lsQQÕ¨eUQ\DĦ[Vĸsďl[UhÇŸl’lShli2ģ\h`ªeIÍ KARNATAKA

State where appeared for 2nd PUC/12th/Equivalent :
II.17(j). Īs`ƒ£lsī[hľ£lsQQÕ¨eUQ\DĦ[Vĸsďl[UhÇŸl’lShli2ģ\h`ĝ¬lÐ MYSURU
District where appeared for 2nd PUC/12th/Equivalent exam :
II.17(k). cÄĺsBªeIÍNative State : KARNATAKA

II.17(l).cÄĺsBĝ¬lÐNative District : MYSURU (MYSORE)

II. 18. Īs`ƒBjĽBlisšeSģ[ĹÐIJsc¬eĦ[UhÇVœl[^h4dĸ\hĻªe!

¥eś±ltŖՐlisŤDĺ’l No
¨eQÎ4UÒĵchQál
Are you claiming Agriculturist Quota Reservation?
Printed Date: 22-05-2020 05-29-08 Page No: 2
 Edited Incomplete Application APP No: 145791

II. 18.a. BjĽ¤eÎŴsĖBVĸsďlls2SÎ

Agriculture Practical Exam Centre:

III . ®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

ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 1 2008 2009 2009

ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 2 2009 2010 2010
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 3 2010 2011 2011
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 4 2011 2012 2012
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 5 2012 2013 2013
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 6 2013 2014 2014
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 7 2014 2015 2015
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 8 2015 2016 2016
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 9 2016 2017 2017
ST JOSEPHS CONVENT K R NAGAR MYSORE DIST 10 2017 2018 2018
ALPHA PU COLLEGE K R NAGAR TALUK MYSORE DIST 11 2018 2019 2019
ALPHA PU COLLEGE K R NAGAR TALUK MYSORE DIST 12 2019 2020 2020
Declaration
75Ŗ¬ltŖZh‘e2Q\Īsģ\h`<¬eвlsĺlD_…¨eĿĦD_…UZ’lĦĺSZġ¾’lcQͲeDhĪC\®l2Sh7Zi^B
ęisĽchŸlÃs®l75Ŗ¬ltŖ4ĝQh2Xh`ƒSl´c2X2ĩľS2Ÿl¨eĿĦltīģ[ĹвeDhl6<®lř±ltōUĹÐĪsģ\h`<¬eÐ
¨eĿĦciG£lD_UhÇQh2¦e<G¹ĸlĵ2S@Ĩ\hŸlÃs®l?2Sh®ls­l£e`ƒ5Ŗ¬ltŖZh‘e2Q\Īsģ\h`©e`ƒ¡ls¨eĿĦ[h
QVƒÈ4R®e4cQÍ®l2ShB2NhX2SĹÐB£eLBVĸsďe¤eÎĩe\`ƒ7c2X2TUZÌĻ\hSÆŸl’lShli_ÑXdh¡eSeUiUh
ĸsĦ[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 are also
liable for 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: 22-05-2020 17:17:26

ah^´c2¡e[Ļ`\Payment Status
4ĝah^´ 500 ¦eÍ2Ń²lc\h online INB
Application Fees : Bank Name :
¦eÍ2Ńc2‘lÍ RSM2851316663 ah^´c2¡e[Ĩ£e2B 11-02-2020
9
Bank Ref No : Date of Payment:
¤eÎ2ah¤e^\D—lšlŏ5ĬscŝcĿPrincipal / Gazetted Officer Signature
²lc\hName :

Printed Date: 22-05-2020 05-29-08 Page No: 3

 Edited Incomplete Application APP No: 145791

V†PcĿSignature :

ūd\hSeal:

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.
Details of reservation claimed by the candidate
Clause Code a Name of the Caste VEERASHAIVALINGAYATH
A
10 Years Rural Study No Reservation Category Category-3B

10 Years Stury in Kannada No Article 371(J) Hyderabad Karnataka No

Medium
Agriculturist Quota No J&K Migrant No

NCC No DEFENCE No ANGLO-INDIAN No

SPORTS No EX-DEFENCE No CENTRAL ARMED POLICE No

FORCE
SCOUTS & GUIDES No PH (Differently abled) No
EX-CENTRAL ARMED POLICE No
FORCE

Printed Date: 22-05-2020 05-29-08 Page No: 4