Application Number :

Edited Copy 2021319276

Candidate's Details
1 Course/s Applied for PGCET : M C A (only)FullTime

2 Name of the Candidate : MYNAVATHI B M

3 Name of the Father : MAHESH B P
4 Name of the Mother : NETHRAVATHI
5 Date of Birth : 16:11:2000

6 Gender : Female 7 Quota : Karnataka

8. Marital Status Single Spouse Name

9. Annual Income of the family from All Sources (If married include your spouse 50000
income also)
10 Category : Category-3B 10 a. Sub-Caste : VEERASHAIVA LINGAYTH
Income RD Number (RD00-------) RD3038298024059 Caste RD Number
starting with (RD0--------)

Mother Tounge

11 Religion : Hindu Other

12 Eligibility Clause Code: a
13 Qualifying Degree / Engineering Branch ? B.C.A (3 Years Degree)

Study Information
Qualifying Degree Status ? Completed University Seat No : (USN) BC181960
Qualifying Degree College Name : JSS COLLEGE FOR Qualifying Degree University UNIVERSITY OF MYSORE
WOMEN,CHAMARAJANA Name :
GAR
Total Number of Years of Study in Karnataka : 15
Particulars of Result Month of Passing Year of Passing Maximum Marks Secured Marks
Examination
1 Pass May 2019 1200 778

2 Pass September 2020 1000 708

3 Pass September 2021 800 635

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 :

PGCET Exam Appearing Course Name :

Have you Appeared for GATE during 2019 to 2021 ?

GATE Code :

GATE Score : 0

Do You Claim Seat under Sponsered Quota?

17. PGCET Examination Place 1 CHAMARAJNAGAR

PGCET Examination Place 2 MYSORE (MYSURU)

Candidate's Postal Address for Communication

Address : BISALAVADI VILLAGE AND POST,CHAMARAJANAGAR TALUK,CHAMARAJANAGAR
DISTRICTCHAMRAJNAGAR,CHAMARAJNAGAR,KARNATAKA-571127
Mobile No : XXXXXXXXXX
Email : XXXXXXXXXX@XXXXXXXX

Declaration
 Application Number :
Edited Copy 2021319276

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 Authority for PGCET-2021
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 Declared Date: 22:10:2021 10:10:59

Candidate

Principal / Gazetted Officer Signature

Name:
Signature:

Seal:

PAYMENT STATUS
BANK Ref NUMBER : 20210916010484235 NAME OF THE CANDIDATE : MYNAVATHI B M
APPLICATION FEES : 650 BANK NAME : RTGS/NEFT Payments from any
Bank Account to Indian Bank

Printed Date 07-12-2021 06-03-56