APPLICATION FORM FOR COMEDK UGET-2013

For those intending to apply to member institutions seeking admissions

to 1st Year MBBS/BDS/BE for the year 2013-2014
_____________________________________________________________________________________________
Application Number:
100177
Applicant Name: KUMAR DHARMASENA
Course Applying for: BOTH
Date of Birth: 22/03/1995
Please affix your
recent passport size
colour photograph
here (inside the box)
Test Location Choice: MANGALORE
Gender: MALE
Nationality: INDIAN
Belongs to: KARNATAKA
By Birth / Domicile: BY BIRTH
Category: GM
Parent's Annual Income: 350000.00
Address: AREWA
BEJAI
KSRTC
City: MANGALORE
State: KARNATAKA
Pincode: 587704
Phone No.: 822233442 Mobile No.: 9876543210
Email ID: ptale@gmail.com
Parent's/Guardian's Name: PATIL PUTTAPPA
Payment Details:
DD No.: 100998877 DD Amount: Rs.1500/-
DD Date 11/03/2013
Drawee Bank: STATE BANK OF MYSORE
Name of Institution Last
Studied:
SARADAR VAALABABHAI PU COLLEGE
Place of Institution Last Studied: MANGALORE
Year of Passing: 2013
10th Std Registration Number: 234561234
Declaration: I hereby declare that the particulars given in this form are true to the best of my knowledge
& belief.
Page 1 of 4 Print Application
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Date: Place:

Page 2 of 4 Print Application
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Note: The Following enclosures to be attached along with the application form in the below
mentioned order:
Demand Draft has to be drawn from the nationalized bank in favour of "COMEDK" (check
for the correct spelling), payable at Bangalore (DD must be payable at Bangalore
only). Rs.1200/- (One Thousand Two Hundred Only) for 3 subjects (PCB or PCM) i.e.
MBBS/BDS or B.E and Rs.1500/- (One Thousand Five Hundred Only) for 4 subjects
(PCMB) i.e. MBBS/BDS and B.E..

Application number, applicants name & contact number to be written at the back of the
Demand Draft. Check for the bankers signature on the Demand Draft.
1.
Printed Online Application Form
The completed application form must have
2.
Candidates photo should be pasted (within the box provided)
Candidates signature (within the box provided)
Left forefinger impression of the candidate (within the space provided)
Candidates parent/guardians signature (within the box provided)
Printed Online Date of Birth Certificate / Identity Proof (COMEDK copy).
Date of Birth Certificate / Identity Proof; is an auto generated document which is generated
along with the application form. It is printed as Date of Birth Certificate / Identity proof
(COMEDK Copy). This document needs to be duly signed by the candidate.
The completed Date of Birth Certificate / Identity Proof must have
3.
Candidates photo should be pasted (within the box provided)
Candidates signature (within the box provided)
Photocopy of 10th Standard Marks Card or School Leaving Certificate indicating the
candidate's Date of Birth.
4.
Candidates belonging to SC, ST and OBC of Karnataka would be considered, provided they
furnish the Photocopy of the following Certificates:
SC / ST: Caste Certificate issued by competent authority (Authorised to issue such a
certificate but not below the rank of a Tahsildar)
a.
OBC: Category I, IIA, IIB, IIIA and IIIB: As notified by the Karnataka Govt. Caste and Income
Certificate issued by Tahsildar or higher revenue jurisdictional authority authorised to issue
such a certificate.
b.
MINORITY: Religious (Christian) of All India / Linguistic (Tulu/Telugu/Konkani) of Karnataka
minority candidates to produce certificate as per Annexure-4 of Brochure.
c.
Candidates who have not produced appropriate supporting documents for claiming the status of
Religious / Linguistic Minority / SC / ST / OBC are liable to be considered as General Merit Candidates.
Note:
Kindly send the Application form and the enclosures in A4 size cover only.
Avoid stapling of Demand Draft to the application form. Instead use clips.
Application form must have candidate's signature, left forefinger impression and
Parent/Guardian's Signature.

Applications without the specified enclosures mentioned above will be REJECTED without prior
intimation to the candidates and the application fee will not be refunded.

Do not Sign and no attestation is required on the photograph.

Please take a print of both COMEDK and Candidate copies of Date of Birth Certificate.
Printed online COMEDK Copy of Date of Birth Certificate /Identity Proof is mandatory for processing the
Application form.

Printed online Candidate Copy of Date of Birth Certificate /Identity Proof is required to be carried during the
Test Day as part of your Identity Proof.

The completed Application Form with all the enclosures mentioned above should reach COMEDK office by
speed post or courier on or before 15th April 2013(Monday) to the following address.
Executive Secretary - COMEDK,
# 132, Second Floor, 11th Main,
17th Cross, Malleswaram, Bangalore 560055,
Karnataka. Phone:080-41132810

Page 3 of 4 Print Application

12/03/2013 https://www.comedk.org/main/UGET/UG_PrintApplication.aspx

Print this Application Print Date of Birth Certificate
Page 4 of 4 Print Application
12/03/2013 https://www.comedk.org/main/UGET/UG_PrintApplication.aspx