Confirmation Copy APP No: 117638

[4cd87f25ee3532e6b5b35c4a662d98bd]
5Ŗ¬ltŖ4ĝOnline Application Form

I.Student Information
4ĝc2‘lÍApplication Number 117638

I . 1. 4YÍħ[²lc\hCandidate Name : DEEPAK SIDDAPPA KURABET

4YÍħ[²lc\h

I . 2. Q2¡l[²lc\hFather Name : SIDDAPPA SHETTEPPA KURABET

Q2¡l[²lc\h

I . 3. Ÿeĵ[²lc\hMother Name : GANGAVVA SIDDAPPA KURABET

Ÿeĵ[²lc\h

I . 4. dhġ¾SĨ£e2BDate of birth : 07-06-2002

I . 5. Ĺ2DGender : Male

I . 6. 4YÍħ[c2VBSū¦ltşc2‘lÍ XXXXXX0674 I . 7ªeĽĄs[Ÿl Indian

Candidate Contact Mobile Number : Nationality

I . 8. 6ijsşĻ­ecE-Mail-Id : NAGARXXX

I . 9. 4YÍħ[c2VBS42•lĻ­ecCandidate's Postal Address for Communication

Ļ­ec H.NO1223, KALMESHWAR NAGAR SULEBHAVI, T/DBELAGAVI, BELGAUM,
BELAGAVI (BELGAUM), KARNATAKA - 591103
Address :
9 (f) V©e[ū¦ltşc2‘lÍ XXXXXX1310
Alternative Mobile Number :
I . 10. Ŀ2ĨU`bD_ľ6ġVĸsďeĻ`\Details of Appearing Previous CET Exams
I . 10(a). Īs`ƒĿ2ĨU`bD_ĹÐCET / NEET / NATA Vĸsďl[UhÇŸl’lShli2ģĨÅsªe! No
Have you appeared for previous CET / NEET / NATA Exam ?
II Reservation Details
II. 1. 4dŸeB2ģllisŏ4UhÇ5Ķ´¨eģEligibility Clause Code : a

II . 2. TZReligion : Hindu

II . 3¨eQj§e°l
ci´şe¬lsŊªleŏVΐe\ KANNADA
Mother Tongue
II. 4. Īs`ƒ<Ť<Ť<şľ£lsQ\DĦ[UhÇB£eLBSĹЮeÍc2D¨eģĨÅsªe! Yes
Have you studied SSLC/10th standard in Karnataka?
II . 5Īs`ƒ104R®e12£ls¦lisŏVĸsďl4R®e<\NiVĸsďlB£eLBSĹÐ Yes
XªlĨĨÅsªe!
Did you write Board Exam of 10th/12th/Both in Karnataka?
II. 6B£eLBSĹÐ
1ĸ2S12£lsQ\DĦ`ªl’l®eÍc2D¨eģŸlsDœl²li2ĨSV†P 11
`bD_…
Total number of completed years of study in Karnataka (From 1st to 12th Std.)
II. 7Īs`ƒ¢eIJB4^Èc2‘eÍQIJsc¬eĦX[chĦÃsªe! No
Are you claiming Religious Minority Quota ?

®ltSÍĔs[ZQhÃS2Q®ltSÍĔs[lisŤDĺ’l¨eQÎZhľÐ2ZQhÃĔÎļ¹[Ŗ
only for medical and dental courses (Muslim /Christian)
II. 8. Are you claiming Linguistic Minority Quota ? No

®ltSÍĔs[ZQhÃS2Q®ltSÍĔs[lisŤDĺ’l¨eQÎ
only for medical and dental courses (Tulu/Tamil/Telugu/Kodava)
6ShĪs`ƒUZiĨľ\h`¨eQj§e°lB£eLBSĹЮeÍc2D¨eģS`bD_…104R®e12
£lsQ\DĦ[¦lisŏVĸsďl²eDieÐŤlisŏijs¬l4`^2İQ®eĖ\hQál
Note : It depends on Mother Tounge ,Number of years study in Karnataka ,
Board Exam of 10th/12th/Both in Karnataka. and clause code 'a'

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 Confirmation Copy APP No: 117638
[4cd87f25ee3532e6b5b35c4a662d98bd]
II . 9. —eĦ[²lc\hName of the Caste : HINDU MARATHA

II . 9.(a). Īs`ƒ5Ķ´¨eģ\h`IJsc¬eĦ`D Category-3B

Reservation category you have selected :
II . 9.(b). Caste Certificate RD Number
II . 9.(c). Income Certificate RD Number rd4038152213094

II. 10BhLh2XS®eĽB`\¨eU<¬eÐZi^Dĺ2S\iD_ĹÐ 18000

Annual Income of the family from all sources in Rupees :
II. 11. 5ġBş371(J) ²ltSªe¦eŔB£eLBlisšeSģ[ĹÐIJsc¬eĦVœl[^h4dĸ\hĻªe! No
Are you claiming reservation under Article 371(J) Hyderabad Karnataka ?
II . 12. Īs`ƒĸ2S£lsQ\DĦ[`ªl’lB£eLBS’eÎIJsPVΡlsaSĹЮeÍc2D¨eģĨÅsªe! Yes
Have you studied in Rural area of Karnataka from 1st to 10th standard ?
II . 13. Īs`ƒĸ2S£lsQ\DĦ[`ªl’lBUÇN¨eTÍZSĹЮeÍc2D¨eģĨÅsªe! Yes
Have you studied in Kannada Medium from 1st to 10th standard ?
II. 14. Ļ¯lsbIJsc¬eĦ`DSpecial Category Reservation :

II. 15Īs`ƒ2020\±e¨eUÍVήlsaVĸsďlXªl[^h6ěºch`cÄ_5Ķ´¨eģ BELAGAVI (BELGAUM)

Select the place you wish to appear for CET-2020
II. 16. Īs`ƒIZh̐eļŮĸ`^±l’e\\ZDZD­l!Are you a Son/Daughter of Jammu & No
Kashmiri Migrant ?

II.17. VĸsďeĻ`\D_…Examination Details

II.17(a). 4dŸeVĸsďlQualifying Examination Board: Karnataka 2nd PU Science

II.17(b). ĻaÒĻ¡eÍ^[¦lisŏ²lc\hMention the University / Board Name :

II.17(d). B£eLBľİ<Ť6ľ><Ťľ65ĖSÅĹÐci´ş²lc\hIf Karnataka CBSE / CISCE

School Name :
II.17(e). B£eLB£lsī[hľ
ĻĐeU\®eĽBVĸsďl’l²eIªeDhĻªe! Yes
Are you appearing for Karnataka 2nd PUC Annual Examination 2020 (Science) ?
II.17(f). ī[hci¾œl2ōc2‘lÍPUC Student Number : 2019DD0070158

II.17(g). 6^ЮeSĹПlsDœl©eS`b`UhÇUZiĨľIf No Enter the Year of Passing :

II.17(i). Īs`ƒ£lsī[hľ£lsQQÕ¨eUQ\DĦ[Vĸsďl[UhÇŸl’lShli2ģ\h`ªeIÍ KARNATAKA

State where appeared for 2nd PUC/12th/Equivalent :
II.17(j). Īs`ƒ£lsī[hľ£lsQQÕ¨eUQ\DĦ[Vĸsďl[UhÇŸl’lShli2ģ\h`ĝ¬lÐ BELAGAVI
District where appeared for 2nd PUC/12th/Equivalent exam :
II.17(k). cÄĺsBªeIÍNative State : KARNATAKA

II.17(l).cÄĺsBĝ¬lÐNative District : BELAGAVI (BELGAUM)

II. 18. Īs`ƒBjĽBlisšeSģ[ĹÐIJsc¬eĦ[UhÇVœl[^h4dĸ\hĻªe!

¥eś±ltŖՐlisŤDĺ’l Yes
¨eQÎ4UÒĵchQál
Are you claiming Agriculturist Quota Reservation?
II. 18.a. BjĽ¤eÎŴsĖBVĸsďlls2SÎ Kittur Rani Channamma
College of Horticulture,
Agriculture Practical Exam Centre:
Arabhavi, Gokak

III . ®eÍc2DĻ`\D_…£lsQ\DĦĵ2Sī[hľ£lsQ\DĦ4dŸeVĸsďl[`ªl’l
STUDY DETAILS : From 1st standard to II PUC / 12th standard / Qualifying Examination
ci´şe¬lsĝUĻ­ecZQhÃSi\®eĥc2‘lÍ ®eÍc2DS ®eÍc2DS ®eÍc2DS ŸlsDœl©eS
Complete Name & Address of the School / College with Q\DĦD_… ¤eÎ\2ıB`b li£l[`b `b
Telephone Number
Classes Year of study Year of Year of
Studied From study To Passing

Kannada Higher Primary School, Sulebhavi 1 2008 2009 2009

Kannada Higher Primary School, Sulebhavi 2 2009 2010 2010

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 Confirmation Copy APP No: 117638
[4cd87f25ee3532e6b5b35c4a662d98bd]
Kannada Higher Primary School, Sulebhavi 3 2010 2011 2011
Kannada Higher Primary School, Sulebhavi 4 2011 2012 2012
Kannada Higher Primary School, Sulebhavi 5 2012 2013 2013
Kannada Higher Primary School, Sulebhavi 6 2013 2014 2014
Kannada Higher Primary School, Sulebhavi 7 2014 2015 2015
Government High School, Sulebhavi 8 2015 2016 2016
Government High School, Sulebhavi 9 2016 2017 2017
Government High School, Sulebhavi 10 2017 2018 2018
Govindram Seksaria P.U. Science college 11 2018 2019 2019
R.P.D college road, Tilakwadi, Belagavi 590006
Phone 0831 2485193
Declaration
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.

ŪsbB\V†PcĿ<N 4YÍħ[<Nlt²l¦lÊ\_Dh\hQh 4YÍħ[V†PcĿ

lt²l¦lÊ\_Dh\hQh Left Hand Thumb Signature of the
impression of the Candidate Candidate
Signature of the Parent
/ Guardian
Date: 09-02-2020 22:47:25

ah^´c2¡e[Ļ`\Payment Status
4ĝah^´ 500 ¦eÍ2Ń²lc\h online INB
Application Fees : Bank Name :
¦eÍ2Ńc2‘lÍ RSM2850679633 ah^´c2¡e[Ĩ£e2B 09-02-2020
7
Bank Ref No : Date of Payment:
¤eÎ2ah¤e^\D—lšlŏ5ĬscŝcĿPrincipal / Gazetted Officer Signature
²lc\hName :

V†PcĿSignature :

ūd\hSeal:

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.
Details of reservation claimed by the candidate

Printed Date: 09-02-2020 10-52-43 Page No: 3

 Confirmation Copy APP No: 117638
Clause Code a [4cd87f25ee3532e6b5b35c4a662d98bd]
Name of the Caste HINDU MARATHA

10 Years Rural Study Yes Reservation Category Category-3B

10 Years Stury in Kannada Yes Article 371(J) Hyderabad Karnataka No

Medium
Agriculturist Quota Yes J&K Migrant No

NCC No DEFENCE No ANGLO-INDIAN No

SPORTS No EX-DEFENCE No CENTRAL ARMED POLICE No

FORCE
SCOUTS & GUIDES No PH (Differently abled) No
EX-CENTRAL ARMED POLICE No
FORCE

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