5lt4Online Application Form - Student Information

Application Number
4Y[lc\h
Candidate Name ) :
Candidate's
e[lc\h
Mother Name ) :
photo
Q2l[lc\h
Father Name ) :
dhSe2B(Date of birth): 2D(Gender) :

4Y[c2VBSltc2l 6secE-Mail-Id :
Candidate Contact Mobile Number :

eQjel
cielsleVe\Mother Tongue (As per School/College Record) :

9BhLh2XSeB`\eU<eZi^D2S\iD_
Annual Income of the family from all sources in Rupees :
TZReligion : es[lNationality :

sce`DReservation Category :

e[lc\hName of the Caste :

13 a. e`DZQh5e[VePVQS(RD 2Se\2Yli_`c2l

Caste / Category / Income Certificate (Acknowledgement No..start with RD----) :
4deB2llisEligibility Clause Code :

\eeUVlsaVslXl[h`c_
Place where you wish to appear for CET-2017 :
Vse`\D_Examination Details
4deVslQualifying Examination :

ae^[lislc\hMention the University / Board Name :

a. BeLB<6><65Scilc\hIf CBSE / CISCE School Name :

b. BeLBls[h
eU\eBVslleIeDhe!
Are you appearing for Karnataka 2nd PUC Annual Examination 2017 ?
c. [hcil2c2lPUC Student Number :

d. 6^eSlsDleS`b`UhUZiIf No enter the year of passing :

BeLBS
2SlsQ\D`llec2DelsDlli2SVP`bD_
Total Number of completed years of study in Karnataka (From 1st to 12th std.):
s`2SlsQ\D[`llBeLBSesPVlsaSec2Dese!
Have you studied in Rural area in Karnataka from 1st to 10th standard ?
s`2SlsQ\D[`llBUNeTZSec2Dese!
Have you studied in Kannada Medium from 1st to 10th standard ?
5B371(J) ltSeeBeLBliseS[sceVl[^h4d\he!
Are you claiming reservation under Article 371(J) Hyderabad Karnataka ?
20.a. 371(j) VePVQSRD U2XRD Number of 371(j) cerificate :

4Y[c2VBS42lecCandidate's Postal Address for Communication

ecAddress :

sU2XPhone Number :

s`<<<lsQ\D[UhBeLBSec2Dese!
Have you studied SSLC/10th standard in Karnataka?
 Draft Copy

s`ls[hlsQQeUQ\D[Vsl[UhllShli2\h`eI
State where appeared for 2nd PUC/12th/Equivalent :
s`ls[hlsQQeUQ\D[Vsl[UhllShli2\h`l
District where appeared for 2nd PUC/12th/Equivalent exam :
csBeINative State :

25 a. csBlNative District :

s`IZhe`^le\\ZDZDl!Are you a Son/Daughter of Jammu & Kashmiri Migrant ?

lsb`DSpecial Category :

s`BjBliseS[sce[UhVl[^h4d\he!
eltlisDleQ
4UchQl
Are you claiming Agriculturist Quota Reservation?
a. BjesBVslls2S
Agriculture Practical Exam Centre:
2U`bD_6Vse`\Details of Appearing Previous CET Exams
s`2U`bD_6Vsl[UhllShli2se?Have you appeared for previous CET Exam ?

6c2lCET NO :

Vsl[UhllShli2N`bYear of appearance :

6[s`e`eS\hsLUhllShliseZQhelslVlsaVlse!
Have you obtained any seat in CET and taken Admission to college ?
ec2D`\D_lsQ\D2S[hlsQ\D4deVsl[`ll
STUDY DETAILS : From 1st standard to II PUC / 12th standard / Qualifying Examination
cielsUecZQhSi\ec2l ec2DS ec2DS ec2DS lsDleS
Complete Name & Address of the School / College with Q\DD_ e\2B`b lil[`b `b
Telephone Number
Classes Year of study Year of Year of
Studied From study To Passing

Declaration
 Draft Copy

75ltZhe2Q\s\h`<elslD_eD_UZlSZlcQeDhC\l2Sh7Zi^Bischlsl7
5lt4Qh2Xh`Slc2X2S2lelt[eDhl6<lltUs\h`<eeciGlD_UhQh2e
<Gl2S@\hlsl?2Shlsle`5ltZhe2Q\s\h`e`lse[hQV4Re4cQl2ShB2NhX2S
e`sLUh5eNh`ZQhl6<2SsLUhd2lVl[h`dBUhBlShli_lsleDheIce\BeLBVse
ee\`7c2X2TUZ\hSllShli_XdheSeUiUhs[BZDlXSe\hlsl
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 shall forfeit the claim
to be considered or a seat selected and allotted by KEA. We are also liable for civil and criminal action, that the State
Government or the KEA may take against us in this regard.

sbB\VPc<N 4Y[<Nltll\_Dh\hQh 4Y[VPc

ltll\_Dh\hQh Left Hand Thumb Signature of the
impression of the Candidate Candidate
Signature of the Parent
/ Guardian

Date:

e2ahe^\Dll5sccPrincipal / Gazetted Officer Signature

lc\hName :

VPcSignature :

d\hSeal:

ah^c2e[`\Payment Status

4c2l 4Y[lc\h
Application Number: Name of the Candidate:

4ah^ e2642lBlslc\h
Application Fees: Bank/e-post office Name :
e2642lBlsah^ e2642lBls8lsCc2l
Bank/e-Post office Bank/e-post office Ref No :
Charge

?Lhah^ ah^c2e[e2B
Total Amount: Date of Payment:
DZ1<eVVPli2NU2Q\4Y[h42ZV[UhZhli2NheCl
eBh2Vs^lc2SYS
Be[ecclsBh
2sLhd2lV[cZ[S?Sch`eZQh5e[VePVQ`5lt4[cZ[SUZiSeZQh
5e[`Be[e?2ls5\lsBh42Zisbl[U2Q\e`lse\PBie[XSe`ll4`ea\h`^
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.