Application Number :

2021308959
Candidate's Details
1 Course/s Applied for PGCET : M C A (only)FullTime

2 Name of the Candidate : MANASA M

3 Name of the Father : MAHADEVASWAMY
4 Name of the Mother : NAGARATHNA A M
5 Date of Birth : 06:02:2001

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 11000
income also)
10 Category : Category-3B 10 a. Sub-Caste : VEERASHAIVA LINGAYATHA
Income RD Number (RD00-------) RD0038297095638 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 ? Appeard University Seat No : (USN) BC181959
Qualifying Degree College Name : JSS COLLEGE FOR Qualifying Degree University UNIVERSITY OF MYSORE
WOMEN Name :
CHAMARAJANAGAR
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 July 2019 1200 807

2 Pass September 2020 1000 752

3 Pass October 2021 800 659

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 MYSORE (MYSURU)

PGCET Examination Place 2 HASSAN

Candidate's Postal Address for Communication

Address : AMMA NILAYA NEAR SENT JOSEPH SCHOOL ,CHAMARAJANAGAR
,CHAMARAJANAGARCHAMRAJNAGAR,CHAMARAJNAGAR,KARNATAKA-571313
Mobile No : XXXXXXXXXX
Email : XXXXXXXXXX@XXXXXXXX

Declaration
 Application Number :
2021308959

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: 08:09:2021 12:14:18

Candidate

Principal / Gazetted Officer Signature

Name:
Signature:

Seal:

PAYMENT STATUS
BANK Ref NUMBER : 20210914008100254 NAME OF THE CANDIDATE : MANASA M
APPLICATION FEES : 650 BANK NAME : RTGS/NEFT Payments from any
Bank Account to Indian Bank

Printed Date 04-12-2021 10-43-51