Karnataka Examinations Authority

BANGALORE

No. ED/KEA/ADMN/CR-13/2019(P) Date: 21-08-2020

NOTIFICATION
CET-2020 – Original documents to be kept arranged for uploading of documents
 Seat allotment for admission to various Professional Courses for the year 2020, will be based on
the documents / certificates uploaded by the eligible candidates.
 In this regard, candidates have to upload the relevant documents / certificates issued by
Competent Authority for verification as per their claims made in the online application to claim
eligibility and reservation benefits.
 Hence, be prepared with all the necessary certificates / documents with two sets of copies
(xerox) duly attested by Gazetted Officer.
 Documents / certificates uploaded by the candidates will be considered for verification of all the
disciplines to which the candidate is eligible. Eg: Engineering, Architecture, AYUSH, Farm
Science, B-Pharm and Pharm-D, ## Medical and Dental courses.
 The candidate should possess all necessary original documents with them in support of their
claim made in the online application. If any candidate fails to upload any of the documents /
certificates / marks card, such candidate will not get eligibility to exercise the options for seat
allotment.
Eg:
 If a candidate claimed 3A caste category reservation in the online application and fails to
obtain & produce the Caste cum Income Certificate issued by the concerned Tahasildar,
then he / she will not be eligible to claim 3A reservation.
 If a candidate mentioned as ‘YES’ for Rural reservation in the online application, but fails
to produce the Rural Study Certificate for having studied 1 to 10th standard in the rural
areas issued by the Competent Authority, then such candidate will not be eligible to
claim Rural Reservation.
 Likewise, submission of relevant certificate / documents is mandatory to claim any
reservation benefits; candidates will become ineligible to be considered under that
particular reservation due to non-submission of the relevant certificates / documents.

## MEDICAL / DENTAL courses

Those who are appearing for UGNEET-2020, may please note that the documents which they are
uploading for Engineering etc courses will also be considered for Medical / Dental / AYUSH courses if
they become eligible in UGNEET-2020. Further, candidates claiming additional reservations like
Linguistic Minority / Religious Minority / NRI ward for Medical and Dental courses and admission to St.
Johns Medical College, may keep the Linguistic Minority / Religious Minority / NRI ward certificates
ready. The details will be hosted on the KEA Website separately.

The Linguistic Minority, Religious Minority and NRI Ward reservations are not applicable for
Engineering, Architecture, Veterinary, Farm Science, B-Pharma, Pharma-D, AYUSH courses.

1
Sl.
Details of the Documents / Certificates
No.
Final print out of the CET-2020 Online Application Form. (final edited copy, in case of editing of
01
application)
02 ‘CET 2020’ Admission Ticket.
03 SSLC / 10th Standard Marks Card.
2nd PUC / 12th Standard Marks Card.
 If a candidate has not received the original marks card of Qualifying
Examination for 2020 from the concerned boards, then the candidate should
04
obtain the signature of the Principal of the institution where he / she has
passed 2nd PU / 12th Standard examination on the provisional marks card.
 Internet downloaded marks statement printout will not be accepted.
SEVEN Years Study Certificate counter signed by the concerned BEO / DDPI.
 Study Certificate to show that the candidate has studied in Karnataka for a minimum
period of SEVEN years from 1st standard to 12th standard or qualifying examination
th nd th
issued by Head of the institution including either SSLC / 10 Standard or 2 PUC / 12
05 Standard.
 Further, School study certificates should be countersigned by the concerned Block
Educational Officer (BEO) / Deputy Director of Public Instructions (DDPI)
COMPULSORILY in the proforma prescribed in the following pages.
 Counter signature is not required for CBSE / CISCE study certificate.

The following documents should be kept ready, “ONLY if applicable”:

06 “Income Certificate” All candidates including General Merit candidates are eligible for
Supernumerary quota seats if their annual income is less than Rs.8.00 Lakhs.
 The candidates who claim seat under “Supernumerary Quota” will have to obtain an
income certificate from the concerned Tahasildar.
 SC / ST / Cat-1 and GM candidates should obtain income certificates separately.
 Caste and Income certificate produced by eligible 2A, 2B, 3A and 3B category candidates
will be considered for Supernumerary seats.
07 Kannada Medium Certificate: Candidates who have studied in Kannada Medium from 1st to 10th Std.
in Karnataka and also outside the state of Karnataka.
 Certificate for having studied 10 full academic years in Kannada medium from 1st standard
to 10th standard issued by the Head of the educational institution and such certificate
should be countersigned by the respective BEO or DDPI in the proforma prescribed in the
following pages.

2
08 Rural Study Certificate
 The candidates who claim seat under rural category will have to obtain a rural study
certificate for having studied 10 full academic years in rural areas from 1st standard to 10th
standard from the respective school / high school issued by the head of the institution
which should be countersigned by the concerned Block Educational Officer (BEO) as per
format shown in the following pages.
 General merit candidates who claims seat in rural category should also submit an income
certificate issued from the concerned Tahasildar along with the rural study certificate as per
format shown in the following pages
09 Caste / Caste Income Certificate
 Candidates seeking reservation benefit should obtain Caste Certificate in Form ‘D’ in case of
Scheduled Castes and Scheduled Tribes; in Form ‘E’ in case of Category -1; a Caste Income
Certificate in Form ‘F’ for Other Backward Classes such as 2A, 2B, 3A and 3B, issued by the
concerned Jurisdictional Tahasildar, in accordance with the Government order No. Sa Ka E 225 BCA
2000 dated 30th March 2002 and No. Sa Ka E 104 BCA 2011 dated 06-02-2012 as amended from
time to time. Annexure-II to this rule is reproduced in the following pages for the information of the
candidates and parents.
 The candidates belonging to SC, ST and Category –1 of the Other backward classes should also
obtain a separate Income Certificate to claim Tuition Fee Exemption from concerned department /
Government of India scholarship as per the prescribed format given in the following pages.
10 Article 371 (j) Hyderabad-Karnataka Region
 Candidates claiming Hyderabad-Karnataka Region Reservation [Article 371 (j)] must obtain
the certificate in Annexure – A (eligibility certificate – rule 3(3)) issued by the concerned
Assistant Commissioner.
11 Parent’s study certificate / Parent’s Hometown certificate / Parent’s Domicile certificate / Parent’s
Employment certificate / Parent’s Cumulative Record / Parent’s Marks Card, etc., for the
candidates claiming eligibility for Government seats based on the domicile / study / employment of
the parent.
12 Duly sworn in Affidavit of the candidate who claims eligibility under Horanadu and Gadinadu
Kannadiga clauses C and D. (Regarding Mother Tongue)
13 IDENTITY CARD issued by the Jurisdictional Deputy Commissioner / District Magistrate /
Rehabilitation Commissioner, for the candidates claiming eligibility for Government seats under
Jammu & Kashmiri Migrants quota.

NOTE:
 Documents required for each eligibility clause are detailed in CET-2020 Information
Bulletin which is already hosted on the KEA Website.
 Provided further that the candidate shall be eligible to claim caste, category and income
benefit only if he has claimed the same in the CET-2020 online application form.

3
 DIFFERENT TYPES OF FORMATS / SPECIMEN OF PRESCRIBED CERTIFICATES
(This Study Certificate PROFORMA is common to all the candidates)

PROFORMA FOR STUDY CERTIFICATE PROFORMA OF THE CERTIFICATE

TO BE PRODUCED BY NCC & SPORTS SPECIAL CATEGORY CANDIDATES
(To be obtained from the Schools / Colleges)
NAME, FULL POSTAL ADDRESS & TELEPHONE NUMBER OF THE
INSTITUTION. NAME, FULL POSTAL ADDRESS & TELEPHONE NUMBER OF THE
Date ….…............... INSTITUTION.
This is to certify that Sri. / Kum. ........................ Date ….…...............
.......………. S/o / D/o ..........................……..............……..
has studied from ..............…......... standard to This is to certify that Sri. / Kum. ...............................……………. S/o
.……............. standard in our institution from / D/o ..................................……............... has participated in
…………………...... to ………..……........ academic
..............…......…………….. NCC Camps / Sports events,
years. The mother tongue of the candidate is
……………………………… as per the Admission register of the when he / she was a student of this institution
institution. The above details are true and correct to the best during ……………………. Standard. This is as per the NCC
of my knowledge. / Sports records maintained by this institution.
Signature of The above details are true and correct to the best of my
Institution seal Head of the institution knowledge.
(Name in Block letters..........................................) Signature of Head of the institution
Mobile number: (Name in Block letters..........................................)
Mobile Number:
COUNTER SIGNED BY ME

Address, Seal & Office Telephone Number

Institution seal
of the Block Educational Officer / DDPI.
Mobile number:

PÀ£ÀßqÀ ªÀiÁzsÀåªÀÄzÀ°è ªÁå¸ÀAUÀ ªÀiÁrzÀ §UÉÎ zsÀÈrÃPÀgÀt ¥ÀvÀæ AFFIDAVIT TO BE PRODUCED BY THE FATHER /
MOTHER OF THE HORANADU & GADINADU
KANNADIGA CANDIDATES ONLY
²æà ………………. gÀªÀgÀ ªÀÄUÀ / ªÀÄU¼ÀÄ …………. EªÀgÀÄ ………………………f¯ÉèAiÀÄ (TO BE TYPED ON RS. 20/- STAMP PAPER)
…………. vÁ®ÆèQ£À …………. UÁæªÀÄzÀ°è ªÁ¸ÀªÁVgÀĪÀ EªÀgÀÄ ………… vÀgÀUÀw¬ÄAzÀ
I, Sri. ….…………..………………………………… ……. .……… …
…...…. vÀgÀUÀwAiÀĪÀgÉUÉ ………..…... ±ÉÊPÀëtÂPÀ ªÀµÀð¢AzÀ ……………. ±ÉÊPÀëtÂP
ªÀóµÀðzÀªÀgÉUÉÀ …...…………… ±Á¯ÉAiÀÄ°è PÀ£ÀßqÀ ªÀiÁzsÀåªÀÄzÀ°è ªÁå¸ÀAUÀ S/o ………….…………..…………… Aged ……….… years
ªÀiÁrgÀÄvÁÛgÉAzÀÄ zsÀÈrÃPÀj¸À¯ÁVzÉ. residing at ………………………………... ………………do hereby

zÁR¯Áw ¸ÀASÉå: : ………………………………………….. solemnly affirm and state on oath as follows:

zÁR¯Áw ¢£ÁAPÀ :……………………………………….. I was a resident of …………………… (place) located at

……………………… District in Karnataka State. Presently
±Á¯É ©lÖ ¢£ÁAPÀ :………………………………………… I am residing at …………………………..… (place) located in
¸ÀÞ¼À : …………..……………… State. My son / daughter Mr. / Kum.
……...……………………….….………….... with CET Number
¢£ÁAPÀ : ……………… has appeared for the Common Entrance Test –
2020. My Mother tongue is ……………………….………….
(Kannada / Tulu / Kodava.) and my son / daughter is able to
read, write and speak Kannada language. In the proof of
Kannada / Tulu / Kodava as the Mother Tongue of myself and
my son / daughter, I have sworn to this affidavit and submitted to
±Á¯ÉAiÀÄ ªÀÄÄSÉÆåÃ¥ÁzsÁåAiÀÄgÀ ¸À» ªÉÄîÄgÀÄdÄ
the KEA for selection of seat under the Horanadu / Gadinadu
±Á¯ÉAiÀÄ ¥ÀÆtð «¼Á¸À, PÉëÃvÀæ ²PÀët C¢üPÁjUÀ¼À ¸À», Kannadiga candidate category.
ªÉƺÀgÀÄ ªÀÄvÀÄÛ zÀÆgÀªÁt ¸ÀASÉå PbÉÃjAiÀÄ «¼Á¸À, ªÉƺÀgÀÄ I declare that the above information is correct to the best of my
knowledge and belief. In case any of the above information is
ªÀÄvÀÄÛ found to be false or incorrect, my son / daughter shall forfeit the
seat allotted by the KEA. I hold myself also, liable for civil or
ªÉƨÉÊ¯ï £ÀA§gï: zÀÆgÀªÁt ¸ÀASÉå criminal action and the Government or KEA, Karnataka may take
ªÉƨÉÊ¯ï £ÀA§gï: appropriate action against me in this behalf.
Date: Deponent
Signature of the Candidate
4
Sworn before me
PROFORMA FOR DEFENCE PERSONNEL UNDER CLAUSE 6(e) PROFORMA FOR DEFENCE PERSONNEL UNDER CLAUSE 6(f)
OF ITEM 6 OF CHAPTER –1 OF BROCHURE and 6 (o) OF ITEM 6 OF CHAPTER –1 OF BROCHURE

This is to certify that Sri / Kum ………………………………………. This is to certify that Sri / Kum ……………………………………….
DOB……………. Class ………… Name and Place of the School DOB……………. Class ………… Name and Place of the School
………………………………………… is the Son / Daughter of service ………………………………………… is the Son / Daughter of service
No. …………….. Rank …………….. Name …………………………… No. …………….. Rank …………….. Name ……………………………
Trade …………………….………. Who is a combatant member of the Trade ………………………. Who is a combatant member of the
………………………………… wef …………………… and has served ………………………………… wef …………………… and presently
/ presently serving at ……………….. (unit) …………………… (place) serving at ………………….. (unit) …………………… (place) wef….
wef…. …………. to …………..Service No. ………..…………… Rank Service No. ………………. Rank …………….. Name ………………
…………………… Name …………..…… Trade …………………. Unit Trade …………………. Unit …………………. Is a defence personnel
…………………….. Is a defence personnel according to definition as according to definition as laid down by Government of Karnataka. His
laid down by Government of Karnataka. His present residential permanent residential address at the time of joining service as per
address as per his service document is ….. his service documents is……………… ……………………… …
…………………………………………………………………………….. ……..………………………………………………………………………
………………………………………………………………………………
…………………………………………………………………………….. Date: (Signature of parent)
Contact Number:
Date: (Signature of parent)
Contact Number: COUNTERSIGNED BY
Unit Seal
COUNTERSIGNED BY Date: Stamp and signature of the
Unit Seal Commanding Officer
VERIFIED BY
Date: Stamp and signature of the
Unit Seal
Commanding Officer. Date: Stamp and signature of
Director at Integrated HQ of
MoD / Chief Records Officer

PROFORMA FOR DEFENCE PERSONNEL UNDER CLAUSE 6(g)

OF ITEM 6 OF CHAPTER –1 OF BROCHURE
DzÁAiÀÄ ªÀgÀªÀiÁ£À zsÀÈrÃPÀgÀt ¥ÀvÀæ

This is to certify that Sri / Kum ………………………………………. J¯Áè ªÀUÀðzÀ C¨sÀåyðUÀ¼ÀÄ CAzÀgÉ ¸ÁªÀiÁ£Àå ªÀUÀðzÀ
DOB……………. Class ………… Name and Place of the School
………………………………………… is the Son / Daughter of service
C¨sÀåyðUÀ¼ÀÆ ¸ÀºÀ ¸ÀÆ¥Àgï£ÀÆåªÀÄgÀj PÉÆÃlzÀ
No. …………….. Rank …………….. Name …………………………… ¹ÃlÄUÀ¼À£ÀÄß ¥ÀqÉAiÀħºÀÄzÁVzÉ. ¸ÀÆ¥Àgï£ÀÆåªÀÄgÀj
Trade ………………………. Who is a combatant member of the
………………………………… wef …………………… who has served PÉÆÃlzÀ ¹ÃlÄUÀ¼À£ÀÄß ¥ÀqÉAiÀÄ®Ä CºÀðvÉAiÀÄ «ªÀgÀUÀ¼À£ÀÄß
at …………………..(Name & place of the unit at Karnataka for a
period of …… (years) …. Months from ………. To …… and is ªÀÄÄA¢£À ¥ÀÄlUÀ¼À°è ¤ÃqÀ¯ÁVzÉ. C¨sÀåyðUÀ¼ÀÄ DzÁAiÀÄ
posted on duty directly to disturbed areas of J & K or North East or in ¥ÀæªÀiÁt ¥ÀvÀæªÀ£ÀÄß ¸ÀA§A¢ü¹zÀ vÀºÀ¹Ã¯ÁÝgÀjAzÀ ¥ÀqÉzÀÄ
Field / Active service (as laid down by ………. Letter No. ………
dated ……… ) at ……………….(Unit)……………….………… Place ¸À°è¸À¨ÉÃPÀÄ.
wef…. .,……. Service No. ………………. Rank …………….. Name
……………… Trade …………………. Unit …………………. Is a
defence personnel according to definition as laid down by ¥À.eÁ, ¥À.¥ÀA ªÀÄvÀÄÛ ¥ÀæªÀUÀð-1PÉÌ ¸ÉÃjgÀĪÀ «zÁåyðUÀ¼ÀÄ
Government of Karnataka. He has been permitted to keep his family
at the following address as per his service document. ¸ÀºÀ ±ÀÄ®Ì «£Á¬Äw ¥ÀqÉAiÀÄ®Ä DzÁAiÀÄ
……………………………………………………………………………..
……………………………………………………………………………… ¥ÀæªÀiÁt¥ÀvÀæªÀ£ÀÄß ¸ÀA§A¢ü¹zÀ vÀºÀ¹Ã¯ÁÝgÀjAzÀÄ ¥ÀqÉzÀÄ
…………………………………………………………………………….. ¸À°è¸À¨ÉÃPÀÄ
Date: (Signature of Parent)

Contact Number:

COUNTERSIGNED BY
Unit Seal

Date: Stamp and signature of the

Commanding Officer.

5
 SPECIMEN OF PRESCRIBED (DIFFERENT TYPES) FORMATS

PROFORMA FOR CAPF / CRPF / CISF / BSF / ITBP UNDER CLAUSE 6(o) OF ITEM 6 OF CHAPTER –1 OF e-BROCHURE

This is to certify that Sri / Kum ………………………………………. DOB……………. Class ………… Name and Place of the Scholl
…………………………is the Son / Daughter of service No. …………….. Rank …………….. Name …………………………… Trade
………………………. Who is / was a combatant member of the ………………………………… wef …………………… and presently
serving at ………………….. (unit) …………………… (place) wef….Service No. ………………. Rank …………….. Name ………………
Trade …………………. Unit …………………. Is / was a CAPF / CRPF / CISF / BSF / ITBP member according to definition as laid down
by Government of Karnataka. His permanent residential address at the time of joining service as per his service documents
is……………………………..………………………………..………………………………………………………………………………….

Date: (Signature of parent)

COUNTERSIGNED BY
Unit Seal
Date: Stamp and signature of the
Commanding Officer
VERIFIED BY
Unit Seal
Date: Stamp and signature of
Director at Integrated HQ of MoD / Chief Records Officer

PROFORMA FOR INCOME CERTIFICATE

TO BE PRODUCED BY GENERAL MERIT CANDIDATES TO CLAIM SUPER NUMERARY QUOTA SEATS

DzÁAiÀÄ / ªÀgÀªÀiÁ£À zÀÈrüÃPÀgÀt ¥ÀæªÀiÁt ¥ÀvÀæ

………..………. f¯ÉèAiÀÄ ……………...………. vÁ®ÆèQ£À …………………. UÁæªÀÄ / ¥ÀlÖtzÀ°è ªÁ¸ÀªÁVgÀĪÀ ²æà / ²æêÀÄw ……………………………… (C¨sÀåyðAiÀÄ vÀAzÉ CxÀªÁ vÁ¬Ä)
gÀªÀgÀÄ ……………………….…. ªÀÈwÛAiÀÄ°è vÉÆqÀVzÀÄÝ, J®è ªÀÄÆ®UÀ½AzÀ CªÀgÀ ªÁ¶ðPÀ ªÀgÀªÀiÁ£À gÀÆ¥Á¬Ä ………………………. EgÀÄvÀÛzÉ. CªÀgÀ ªÀÄUÀ / ªÀÄUÀ¼ÁzÀ
PÀĪÀiÁgÀ / PÀĪÀiÁj ………………………….…. (C¨sÀåyð) EªÀgÀÄ 2020gÀ ¸ÁªÀiÁ£Àå ¥ÀæªÉñÀ ¥ÀjÃPÉëAiÀÄ£ÀÄß vÉUÉzÀÄPÉÆArzÀÄÝ, CzÀPÉÌ ¸ÀA§A¢ü¹zÀAvÉ F
ªÉÄð£À DzÁAiÀÄ / ªÀgÀªÀiÁ£À ¥ÀæªÀiÁt ¥ÀvÀæªÀ£ÀÄß ¥Àj²Ã®£ÉAiÀÄ £ÀAvÀgÀ ¤ÃqÀ¯ÁVzÉ.
¸ÀÞ¼À :
¢£ÁAPÀ :
vÀºÀ¹Ã¯ÁÝgÀªÀgÀ ¸À»
PÀbÉÃjAiÀÄ «¼Á¸À, ªÉƺÀgÀÄ ªÀÄvÀÄÛ zÀÆgÀªÁt ¸ÀASÉå

C£ÀħAzsÀ-J
CºÀðvÁ ¥ÀæªÀiÁt¥ÀvÀæ
[C£ÀÄZÉÒÃzÀ 371(eÉ) CrAiÀÄ°è]
(¤AiÀĪÀÄ 3(3)£ÀÄß £ÉÆÃr)
[¥ÀæªÀiÁt¥ÀvÀæUÀ¼À£ÀÄß ¤ÃqÀĪÀÅzÀPÉÌ ¸ÀA§A¢ü¹zÀ PÀ£ÁðlPÀ ¸ÁªÀðd¤PÀ GzÉÆåÃUÀ (ºÉÊzÀgÁ¨Ázï-PÀ£ÁðlPÀ ¥ÀæzÉñÀPÉÌ
£ÉêÀÄPÁwAiÀÄ°è «ÄøÀ¯Áw) ¤AiÀĪÀÄUÀ¼ÀÄ, 2013]
²æÃ/²æêÀÄw _________ CªÀgÀ ªÀÄUÀ£ÁzÀ/¥ÀwßAiÀiÁzÀ ²æÃ/²æêÀÄw ________ ____________ CªÀgÀÄ PÀ£ÁðlPÀ
gÁdåzÀ ____________ f¯ÉèAiÀÄ ___________ vÁ®ÆèQ£À __________ UÁæªÀÄ/ ¥ÀlÖtzÀ ¸ÀܽÃAiÀÄ ªÀåQÛAiÀiÁVgÀÄvÁÛgÉ.
ºÉ¸ÀgÀÄ:_______________
¸ÀܼÀ:_______ G¥À«¨sÁUÁ¢üPÁj

¢£ÁAPÀ: ______________ G¥À«¨sÁUÀ

______________ f¯Éè

6
 PROFORMA FOR RURAL STUDY CERTIFICATE
 UÁæ«ÄÃt «ÄøÀ¯Áw CrAiÀÄ°è ¹ÃlÄ ¥ÀqÉAiÀÄ°aÒ¸ÀĪÀ C¨sÀåyðUÀ¼ÀÄ ªÉÆzÀ°UÉ vÁªÀÅ ªÁå¸ÀAUÀ ªÀiÁrzÀ ±Á¯ÉAiÀÄ
ªÀÄÄSÉÆåÃ¥ÁzsÁåAiÀÄjAzÀ UÁæ«ÄÃt ªÁå¸ÀAU ¥ÀæªÀiÁt ¥ÀvÀæªÀ£ÀÄß ¥ÀqÉzÀÄ ¸ÀA§AzsÀ¥ÀlÖ PÉëÃvÀæ ²PàëuÁ¢üPÁjUÀ½AzÀ ªÉÄîÄgÀÄdÄ
ªÀiÁr¸À¨ÉÃPÀÄ.
 ¸ÁªÀiÁ£Àå ªÀUÀðzÀ C¨sÀåyðUÀ¼ÀÄ ªÀiÁvÀæ UÁæ«ÄÃt ªÁå¸ÀAU ¥ÀæªÀiÁt ¥ÀvÀæzÉÆA¢UÉ ¸ÀA§AzsÀ¥ÀlÖ vÀºÀ¹Ã¯ÁÝgïgÀªjAzÀ F PɼÀUÉ
£ÀªÀÄÆ¢¹gÀĪÀ £ÀªÀÄÆ£ÉAiÀÄ°è ¥Àj²Ã®£Á ¥ÀæªÀiÁt ¥ÀvÀæªÀ£ÀÆß ¥ÀqÉzÀÄ ¹ÃlÄ DAiÉÄÌ ¥ÀæQæAiÉÄAiÀÄ ¸ÀAzÀ¨sÀðzÀ°è PÀqÁØAiÀĪÁV
ºÁdgÀÄ¥Àr¸À¨ÉÃPÀÄ. E®èªÁzÀ°è UÁæ«ÄÃt «ÄøÀ¯ÁwAiÀÄ ¹ÃlÄUÀ¼À£ÀÄß DAiÉÄÌ ªÀiÁrPÉƼÀî®Ä ¸ÁªÀiÁ£Àå ªÀUÀðzÀªÀjUÉ CªÀPÁ±À
¤ÃqÀ¯ÁUÀĪÀÅ¢®è.
 UÁæ«ÄÃt ªÁå¸ÀAU ¥ÀæªÀiÁt ¥ÀvÀæ ªÀÄvÀÄÛ ¥Àj²Ã®£Á ¥ÀæªÀiÁt ¥ÀvÀæUÀ¼À C¥ÉÃQëvÀ ªÀiÁzÀjUÀ¼À£ÀÄß F PɼÀUÉ ¤ÃqÀ¯ÁVzÉ.

UÁæ«ÄÃt ªÁå¸ÀAUÀ ¥ÀæªÀiÁt ¥ÀvÀæ ¥Àj²Ã®£Á ¥ÀæªÀiÁt ¥ÀvÀæ

²æà ……………… gÀªÀgÀ ªÀÄUÀ / ªÀÄU¼ÀÄ ………… EªÀgÀÄ ………………………f¯ÉèAiÀÄ (¸ÁªÀiÁ£Àå ªÀUÀðzÀªÀjUÉ ªÀiÁvÀæ )

………… vÁ®ÆèQ£À ………… UÁæªÀÄzÀ°è ªÁ¸ÀªÁVgÀĪÀ EªÀgÀÄ ………… 1. ²æà . ²æêÀÄw ………………………………………… EªÀgÀ ªÀÄUÀ : ªÀÄUÀ¼ÀÄ
vÀgÀUÀw¬ÄAzÀ __ vÀgÀUÀwAiÀĪÀgÉUÉ ……… f¯ÉèAiÀÄ …………… vÁ®ÆèQ£À ……………………………………………… JA§ÄªÀgÀÄ PÀ£ÁðlPÀ gÁdåzÀ
……… UÁæªÀÄzÀ ……………… ±Á¯ÉAiÀÄ°è ªÁå¸ÀAUÀ ªÀiÁr …………… ªÀµÀð ……………………………… f¯ÉèAiÀÄ ………………………… UÁæªÀÄ / ¥ÀlÖt /
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