B£eLBce\ Government of Karnataka

B£eLBVĸsďe¤eÎĩe\
UGNEET - 2023
C Karnataka Examinations Authority
UGNEET - 2023

2023-24£ls±eĹUūS^£l[`bS[hĝ®ltSÍĔs[S2Q®ltSÍĔs[5[h®lsS[h£eĪ²lisIJŴsVĦlisŤD_Vήlsal´5Ŗ¬ltŖZi^B
4ĝOnline Application for Admission to First Year UG-Medical/Dental/Ayurveda/Unani/Homeopathy courses for the Year 2023-24

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Appln No:
Declaration. 49202118122867
5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details

4YÍħ[²lc\hCandidate Name : D RAMAKRISHNA SUBRAHMANYAM

Q2¡l[²lc\hFather Name/Guardian Name D BHAVANI PRASAD

Ÿeĵ[²lc\hMother Name D SRI LAKSHMI

dhġ¾SĨ£e2BDate of Birth 27/04/2005

ū¦ltşc2‘lÍ6ijsşMobile Number & Email 95XXXXXX99 - s****d@g****l.com

4YÍħ[ªeĽĄs[ŸlCandidate Nationality INDIAN -

4YÍħ[Ĺ2DCandidate Gender MALE

4YÍħ[Ļ­ecCandidate Address ANJANEYA NAGAR GINEGERA, KOPPAL, KOPPAL,

KARNATAKA - 583228
Caste Reservation Claimed / Income Details

TZReligion HINDU

IJsc¬eĦ`D—eĦ[²lc\hReservation category - 2A - 7ģD

Name of the Caste

—eĦVΨePVQÎ5ģc2‘lÍ RD0038714506410
&DVWH&HUWLILFDWH5'1XPEHU
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD
Number
Annual Income 25000

Other Reservation claimed Details

NCC NO
SPORTS NO
SCOUTS & GUIDES NO
DEFENCE NO
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 NO
STUDY IN RURAL AREAS FROM 1 TO 10TH NO
JAMMU & KASHMIR MIGRANTS NO
KALYANA KARNATAKA (371 (J)) NO

Printed Date: 02-08-2023 12-54-51 Page No: 1

 B£eLBce\ Government of Karnataka
B£eLBVĸsďe¤eÎĩe\
UGNEET - 2023
C Karnataka Examinations Authority
UGNEET - 2023

2023-24£ls±eĹUūS^£l[`bS[hĝ®ltSÍĔs[S2Q®ltSÍĔs[5[h®lsS[h£eĪ²lisIJŴsVĦlisŤD_Vήlsal´5Ŗ¬ltŖZi^B
4ĝOnline Application for Admission to First Year UG-Medical/Dental/Ayurveda/Unani/Homeopathy courses for the Year 2023-24

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Appln No:
Declaration. 49202118122867
Academic Details
lisšeQuota claimed / 4dŸeb\QhÐlisŏEligibility Clause Code KARNATAKA - CLAUSE - A

¨eQj§e°lMother Tongue TELUGU

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 PRIVATE
£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) KOPPAL
ī[hľĻ¡eÍħc2‘lÍŸlsDœl©eS`bPUC Student Number & Year of 2022RK02930071 - 2023
Passing
Īs`ƒB£eLBªeIÍSB£eLBVĸsďeZ2NĺUœlch`<Ť<Ť<şľVĸsďl[ĹÐ NO - 202118122867
ŸlsDœl©eĖ\hĻªls!
Completed SSLC from KSEEB, Govt. of Karnataka? and Registration
Number
Īs`ƒĔ´2QūS^hĪsōVĸsďlDĺ’l²eIªeĖĨÅsªe!ľ6ġc2‘lÍVĸsďlXªlS NO
`b
Have you Appeared for NEET Exams before 2023? / CET 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
SHASHANK CONVEMENT SCHOOL BELLARI BALLARI 1 2012
SHASHANK CONVEMENT SCHOOL BELLARI BALLARI 2 2013
SHASHANK CONVEMENT SCHOOL BELLARI BALLARI 3 2014
SHASHANK CONVEMENT SCHOOL BELLARI BALLARI 4 2015
SHASHANK CONVEMENT SCHOOL BELLARI BALLARI 5 2016
GLOBAL PUB SCHOOL KARATAGI KOPPAL 6 2017
GLOBAL PUB SCHOOL KARATAGI KOPPAL 7 2018
GLOBAL PUB SCHOOL KARATAGI KOPPAL 8 2019
GLOBAL PUB SCHOOL KARATAGI KOPPAL 9 2020
GLOBAL PUB SCHOOL KARATAGI KOPPAL 10 2021

Printed Date: 02-08-2023 12-54-51 Page No: 2

 B£eLBce\ Government of Karnataka
B£eLBVĸsďe¤eÎĩe\
UGNEET - 2023
C Karnataka Examinations Authority
UGNEET - 2023

2023-24£ls±eĹUūS^£l[`bS[hĝ®ltSÍĔs[S2Q®ltSÍĔs[5[h®lsS[h£eĪ²lisIJŴsVĦlisŤD_Vήlsal´5Ŗ¬ltŖZi^B
4ĝOnline Application for Admission to First Year UG-Medical/Dental/Ayurveda/Unani/Homeopathy courses for the Year 2023-24

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Appln No:
Declaration. 49202118122867
SRI SHARADA PU COLLEGE KIDADHAL KOPPAL KOPPAL 11 2022
SRI SHARADA PU COLLEGE KIDADHAL KOPPAL KOPPAL 12 2023

2nd PUC/ 10+2 Marks Physics Chemistry Biology

Payment Details

DZĪľ1<¬eÐVÎĔÎĶV†P’li2NU2Q\4YÍħ[h42ĦZVÎĦ[UhÇZhĨÎľli2Nh¡eC¬l œeBhÍij2ō Vĸļs^£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.

07/03/2023
4YÍħ[cĿ
Left hand Thumb of Declared Date
Signature of the
Candidate
Candidate

Printed Date: 02-08-2023 12-54-51 Page No: 3

 B£eLBce\ Government of Karnataka
B£eLBVĸsďe¤eÎĩe\
UGNEET - 2023
C Karnataka Examinations Authority
UGNEET - 2023

2023-24£ls±eĹUūS^£l[`bS[hĝ®ltSÍĔs[S2Q®ltSÍĔs[5[h®lsS[h£eĪ²lisIJŴsVĦlisŤD_Vήlsal´5Ŗ¬ltŖZi^B
4ĝOnline Application for Admission to First Year UG-Medical/Dental/Ayurveda/Unani/Homeopathy courses for the Year 2023-24

Its only a Edit DRAFT Copy to check the details - Take the FINAL Copy after Appln No:
Declaration. 49202118122867

Printed Date: 02-08-2023 12-54-51 Page No: 4