B£eLBce\ Government of Karnataka

Karnataka Examinations Authority

B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_…42Sªl(B.Sc.
5UŤBjĽB.Sc
5UŤ4\PÍ6ŸeÍĨİ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e
¬eÍL\ş<2ġÎ`jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
3920210553596

5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details

4YÍħ[²lc\hCandidate Name : RAHUL

Q2¡l[²lc\hFather Name/Guardian Name ANANDA POOJARI

Ÿeĵ[²lc\hMother Name RENUKA

dhġ¾SĨ£e2BDate of Birth 07/04/2006

ū¦ltşc2‘lÍ6ijsşMobile Number & Email 90XXXXXX17 - r****8@g****l.com

4YÍħ[ªeĽĄs[ŸlCandidate Nationality INDIAN

4YÍħ[Ĺ2DCandidate Gender MALE

4YÍħ[Ļ­ecCandidate Address 3-158 KANDA THOTA KOLEKADY ATHIKARI BETTU

MULKI, MANGALORE, MANGALURU (DAKSHINA
KANNADA), KARNATAKA - 574154
ľ6ġ\VĸsďecÄ_ūS^5S͟l MANGALURU (DAKSHINA KANNADA)
Exam Place for CET-2023 - First Priority
ľ6ġ\VĸsďecÄ_<\N£ls5S͟l MOODABIDRE
Exam Place for CET-2023 - Second Priority
BjĽlisše4ģ[ĹÐIJsc¬eĦVœl[^hĪs`ƒ4dªeĖĨÅsªe! NO
Are you eligible to claim reservation under
$JULFXOWXULVW4XRWD"
BjĽ¤eÎŴsĖBVĸsďl’l²eIªeD^hcÄ_
Place to appear for Agriculture Practical Exam
Caste Reservation Claimed / Income Details

TZReligion HINDU

IJsc¬eĦ`D—eĦ[²lc\hReservation category - 2A - İ^Ð`

Name of the Caste
—eĦVΨePVQÎ5ģc2‘lÍ RD0038851086258
&DVWH&HUWLILFDWH5'1XPEHU
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD
Number
Annual Income 50000

Other Reservation claimed Details

NCC NO
SPORTS NO
SCOUTS & GUIDES NO
DEFENCE NO

Printed Date: 01-04-2023 11-37-43 Page No: 1

 B£eLBce\ Government of Karnataka
Karnataka Examinations Authority
B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_…42Sªl(B.Sc.
5UŤBjĽB.Sc
5UŤ4\PÍ6ŸeÍĨİ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e
¬eÍL\ş<2ġÎ`jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
3920210553596
EX-DEFENCE (ONLY FOR KARNATAKA) NO
PH (DIFFERENTLY ABLED) NO
ANGLO-INDIAN NO
CENTRAL ARMED POLICE FORCE NO
EX-CENTRAL ARMED POLICE FORCE NO
STUDY IN KANNADA MEDIUM FROM 1 TO 10TH YES -
STUDY IN RURAL AREAS FROM 1 TO 10TH YES -
JAMMU & KASHMIR MIGRANTS NO -
KALYANA KARNATAKA (371 (J)) NO -

Academic Details
lisšeQuota claimed / 4dŸeb\QhÐlisŏEligibility Clause Code KARNATAKA - CLAUSE - A

¨eQj§e°lMother Tongue TULU

Do you write/appearing Board Exam of 12th in Karanataka? Yes
B£eLBSĹÐ?Lh¾`bD_4TÍ[Uc2‘lÍ
ĸ2S£lsQ\DĦ`ªl’l 12
7RWDOQXPEHURI\HDUVRIVWXG\LQ.DUQDWDND)URPVWWRWK6WG
£lsī[hľ£lsVĸsďl[ªeIÍ4dŸeVĸsďeZ2Nĺ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam & Qualifying Examination Board
e¬lsIhVΐe\College Type GOVT. OF KARNATAKA
£lsī[hľ£lsVĸsďl[ªeIÍ4dŸeVĸsďeZ2Nĺ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam & Qualifying Examination Board
District of 2nd PUC/12th/Equivalent exam (if studied in karnatka) MANGALURU (DAKSHINA
KANNADA)
ī[hľĻ¡eÍħc2‘lÍŸlsDœl©eS`bPUC Student Number & Year of 2022SS00110081 - 2023
Passing
Īs`ƒB£eLBªeIÍSB£eLBVĸsďeZ2NĺUœlch`<Ť<Ť<şľVĸsďl[ĹÐ YES - 20210553596
ŸlsDœl©eĖ\hĻªls!
Completed SSLC from KSEEB, Govt. of Karnataka? and Registration
Number
Īs`ƒĔ´2QūS^hľ6ġĪsō£ešeVĸsďlDĺ’l²eIªeĖĨÅsªe!ľ6ġVήlsa NO
ġlōc2‘lÍVĸsďlXªlS`b
Have you Appeared for CET / NEET / NATA Exams before 2023? / CET
Admission Ticket Number / Year of appearance

Study Details
ci´şe¬lsĝUĻ­ec ®eÍc2DS

Name and Address of the School and Address District Q\DĦD_…Passed `bPassed
Class Year
DK JILLA PANCHAYTH SCHOOL ATHIKARIBETTU MANGALURU 1 2012

Printed Date: 01-04-2023 11-37-43 Page No: 2

 B£eLBce\ Government of Karnataka
Karnataka Examinations Authority
B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_…42Sªl(B.Sc.
5UŤBjĽB.Sc
5UŤ4\PÍ6ŸeÍĨİ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e
¬eÍL\ş<2ġÎ`jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
3920210553596
DK JILLA PANCHAYTH SCHOOL ATHIKARIBETTU MANGALURU 2 2013
DK JILLA PANCHAYTH SCHOOL ATHIKARIBETTU MANGALURU 3 2014
DK JILLA PANCHAYTH SCHOOL ATHIKARIBETTU MANGALURU 4 2015
DK JILLA PANCHAYTH SCHOOL ATHIKARIBETTU MANGALURU 5 2016
KPSK MEMORIAL HIGHSCHOOL PANJINADKA MANGALURU 6 2017
KPSK MEMORIAL HIGHSCHOOL PANJINADKA MANGALURU 7 2018
KPSK MEMORIAL HIGHSCHOOL PANJINADKA MANGALURU 8 2019
KPSK MEMORIAL HIGHSCHOOL PANJINADKA MANGALURU 9 2020
KPSK MEMORIAL HIGHSCHOOL PANJINADKA MANGALURU 10 2021
GOVT PU COLLEGE MULKI MANGALURU 11 2022
GOVT PU COLLEGE MULKI MANGALURU 12 2023

Payment Details
AppNo 3920210553596 Bank Ref No. YUP21817726674
Application Fee Rs. 500 Bank Name Bill desk
Paid Date 01/04/2023

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.

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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.

Printed Date: 01-04-2023 11-37-43 Page No: 3

 B£eLBce\ Government of Karnataka
Karnataka Examinations Authority
B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_…42Sªl(B.Sc.
5UŤBjĽB.Sc
5UŤ4\PÍ6ŸeÍĨİ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e
¬eÍL\ş<2ġÎ`jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
3920210553596
01/04/2023
4YÍħ[cĿ
Left hand Thumb of
Declared Date Signature of the
Candidate
Candidate

Printed Date: 01-04-2023 11-37-43 Page No: 4