Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Declaration.

Appln No:
3920130876337

5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details
4YÍħ[²lc\hCandidate Name : SUMANTH S C

Q2¡l[²lc\hFather Name/Guardian Name CHIKKABETTAIAH

Ÿeĵ[²lc\hMother Name JAYALAKSHMI

dhġ¾SĨ£e2BDate of Birth 09/10/1997

Ĺ2DGender MALE

ū¦ltşc2‘lÍMobile Number 88XXXXXX60

6ijsşEmail s****9@g****l.com

ªeĽĄs[ŸlNationality INDIAN

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

Ļ­ecAddress #43, 5TH CROSS, VIGNESHWARANAGARA,

SUNKADAKATTE, BANGALORE
ªeIÍState KARNATAKA

ĝ¬lÐDistrict BENGALURU URBAN (BANGALORE URBAN)

Ÿe^iÐBhTaluk BENGALURU SOUTH

īŖlisŏPin Code 560091

Candidate Type

Candidate experience

Academic Details
lisšeQuota claimed KARNATAKA

4dŸeb\QhÐlisŏEligibility Clause Code CLAUSE - A

Īs`ƒB£eLBªeIÍSB£eLBVĸsďeZ2NĺUœlch`<Ť<Ť<şľVĸsďl[ĹÐ YES
ŸlsDœl©eĖ\hĻªls!
Completed SSLC from KSEEB, Govt. of Karnataka?
B£eLBSĹÐ?Lh¾`bD_4TÍ[Uc2‘lÍ
ĸ2S£lsQ\DĦ`ªl’l 13
7RWDOQXPEHURI\HDUVRIVWXG\LQ.DUQDWDND)URPVWWRWK6WG
Candidate SSLC/10th standard Registration Number (as per markscard) 20130876337
ľ6ġ\VĸsďecÄ_ūS^5S͟l BENGALURU (BANGALORE )
Exam Place for CET-2022 - First Priority
ľ6ġ\VĸsďecÄ_<\N£ls5S͟l TUMAKURU (TUMKUR)
Exam Place for CET-2022 - Second Priority
Caste/ Income

TZReligion HINDU

Printed Date: 27-10-2022 08-05-22 Page No: 1

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Declaration. Appln No:
3920130876337

—eĦ[²lc\hName of the Caste VOKKALIGA

IJsc¬eĦ`DReservation category 3A
—eĦVΨePVQÎ5ģc2‘lÍ
&DVWH&HUWLILFDWH5'1XPEHU
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD Number

¨eQj§e°lMother Tongue KANNADA

Annual Income 10000

Reservation
NCC NO
SPORTS NO
SCOUTS & GUIDES NO
DEFENCE NO
EX-DEFENCE NO
ANGLO-INDIAN NO
CENTRAL ARMED POLICE FORCE NO
EX-CENTRAL ARMED POLICE FORCE NO
KANNADA YES
RURAL NO
KALYANA KARNATAKA RESERVATION NO

Study Details
ci´şe¬lsĝUĻ­ec ®eÍc2DS

Name and Address of School District School Taluk School Q\DĦD_…Class `bYear of
the School Name Name Board
Studied Study To
Govt primary school TUMAKURU KUNIGAL KARNATAK 1-4 2004-2007
santemavathuru (TUMKUR) A

Printed Date: 27-10-2022 08-05-22 Page No: 2

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Declaration. Appln No:
3920130876337

Govt primary school BENGALURU BENGALURU KARNATAK 5-7 2008-2010

kamalanagara URBAN NORTH A
(BANGALORE
URBAN)
Govt high school BENGALURU BENGALURU KARNATAK 8-10 2011-2013
sanegoravanahalli URBAN NORTH A
(BANGALORE
URBAN)
Year status of Result Month of Passing Year of Max Marks Total Marks
Passing Obtained
2 PASS MAY 2020 1450 1092
3 PASS MAY 2021 1375 1067

Nata And Jee Marks Details

Nata Reg No. Nata Max Marks Nata Obtained Nata Exam Date Jee Roll No. Jee
Marks Percentage
0 200 0.00000 01/01/0001 0 0.00000

Payment Details
AppNo 3920130876337 Bank Ref No. YHD41525053096
Application Fee Rs. 650 Bank Name Bill desk
Paid Date 27/10/2022

ęisbžlDeclaration

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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 are also liable
for action, that the State Government or the KEA may take against us in this regard.

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

²lc\hName :

V†PcĿSignature :

ūd\hSeal:

Printed Date: 27-10-2022 08-05-22 Page No: 3

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Declaration. Appln No:
3920130876337

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.

27/10/2022

Declared Date 4YÍħ[cĿ

Left hand Thumb of
Candidate Signature of the
Candidate

Printed Date: 27-10-2022 08-05-22 Page No: 4