Final Copy Edited

Appln No:
2021029471

5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details
4YÍħ[²lc\hCandidate Name : TEJAS P

Q2¡l[²lc\hFather Name PRAKASH V P

Ÿeĵ[²lc\hMother Name SINDHU K M

dhġ¾SĨ£e2BDate of Birth 21/10/2003

Ĺ2DGender Male

ū¦ltşc2‘lÍMobile Number XXXXXXXXXX

6ijsşEmail XXXXXXXXXXXXXXXX

ªeĽĄs[ŸlNationality Indian

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

Ļ­ecAddress SRI KRISHNA NILAYA PAPU STUDIO K M DODDI

ªeIÍState KARNATAKA

ĝ¬lÐDistrict MANDYA

Ÿe^iÐBhTaluk MADDUR

īŖlisŏPin Code 571422

Īs`ƒĔ´2QūS^hľ6ġĪsō£ešeVĸsďlDĺ’l No
²eIªeĖĨÅsªe!
Have you Appeared for CET / NEET / NATA Exams
before 2021?
ľ6ġVήlsaġlōc2‘lÍCET Admission Ticket Number

VĸsďlXªlS`b
Year of appearance
Īs`ƒľ6ġĪsō£ešeZQhÃ<Ŗ<ľÈD_ĹЩe`ƒ¡lsľsLhVœlSh No
e¬lsĝ’lVήlsaVœlĨĨÅsªe!
Have you obtained any seat in CET, NEET, NATA and
taken Admission to college?

Academic Details
lisšeQuota claimed Karnataka

4dŸeb\QhÐlisŏEligibility Clause Code a

B£eLBSĹÐ<Ť<Ť<ĹÕ£lsQ\DĦ@ĨĨÅsªe! Yes
Studied SSLC/10th standard in Karnataka ?
Īs`ƒB£eLBSĹУls¦lisŏVĸsďl[ĹÐXªlĨĨÅsªe²eIªeĖĨÅsªe! Yes
'LG\RXZULWHDSSHDULQJDWWHQGLQJ%RDUG([DPRIWKLQ.DUQDWDND"
B£eLBSĹÐ?Lh¾`bD_4TÍ[Uc2‘lÍ
ĸ2S£lsQ\DĦ`ªl’l 12
7RWDOQXPEHURI\HDUVRIVWXG\LQ.DUQDWDND)URPVWWRWK6WG
4dŸeVĸsďeZ2NĺQualifying Examination Board Karnataka 2nd PU Board
e¬lsIhVΐe\College Type UN-AIDED COLLEGE

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 Final Copy Edited

Appln No:
2021029471
B£eLBľİ<Ť6ľ><ľÕ6S[ĻLh¾¯e¬l[²lc\UhÇ5ĸľ
Karnataka CBSE / CISCE Please Choose School Name
ĻaÒĻ¡eÍ^[¦lisŏ²lc\hUniversity / Board Name

£lsī[hľ£lsc¨eUVĸsďl[ªeIÍ KARNATAKA
State of 2nd PUC / 12th/ Equivalent exam
£lsī[hľ£lsc¨eUVĸsďl[ĝ¬lÐ
B£eLBSĹÐ4TÍ[U¨eģSªl MANDYA
District of 2nd PUC/12th/Equivalent exam (If studied in Karnataka)
B£eLBS£lsī[hľ\Ļ¡eÍħ Yes
6WXGHQWRI.DUQDWDNDQG38&
ī[hľĻ¡eÍħc2‘lÍPUC Student Number 2020PP1580262
ŸlsDœl©eS`bYear of Passing 2021
4YÍħ<Ť<Ť<şľ£lsQ\DĦ£lis2Sĥc2‘lÍ
¨eeÕ؏ŏVΐe\ 20190147183
Candidate S S L C/ 10th standard Register Number (as per markscard)
ľ6ġ\VĸsďecÄ_ūS^5S͟l MADDUR
Exam Place for CET-2021 - First Priority
ľ6ġ\VĸsďecÄ_<\N£ls5S͟l MANDYA
Exam Place for CET-2021 - Second Priority
BjĽlisše4ģ[ĹÐIJsc¬eĦVœl[^hĪs`ƒ4dªeĖĨÅsªe! No
$UH\RXHOLJLEOHWRFODLPUHVHUYDWLRQXQGHU$JULFXOWXULVW4XRWD"
BjĽ¤eÎŴsĖBVĸsďl’l²eIªeD^hcÄ_
Place to appear for Agriculture Practical Exam

Reservations
TZReligion Hindu
Religion Group

—eĦ[²lc\hName of the Caste Vokkaliga

IJsc¬eĦ`DReservation category Category-3A
—eĦVΨePVQÎ5ģc2‘lÍ RD0038771165669
&DVWH&HUWLILFDWH5'1XPEHU
®eĽB5¡e[Annual Income 15000
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD Number RD0038771165669
¨eQj§e°lMother Tounge Kannada
B¬eÍPB£eLBIJsc¬eĦ#Ļĩ
—l% No
Kalyana Karnataka reservation - [Article 371(j)]
B¬eÍPB£eLBS5ģc2‘lÍ
—l
5'1XPEHURI.DO\DQD.DUQDWDNDM
ĸ2S£lsQ\DĦ[`ªl’lB£eLBS’eÎIJsPVΡlsaD_ĹÐV†P¯ltčĥB No
`bD_ĹÐ4TÍ[U¨eģĨÅsªe!
Have you studied in Rural areas of Karnataka from 1st to 10th
standard for 10 full academic years
Īs`ƒĸ2S£lsQ\DĦ[`ªl’lBUÇN¨eTÍZSĹЮeÍc2D¨eģĨÅsªe!Have No
\RXVWXGLHGLQ.DQQDGD0HGLXPIURPVWWRWKVWDQGDUGIRU
full academic years
Are you a Son/Daughter of Jammu & Kashmiri Migrants No
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Appln No:
2021029471
Īs`ƒ¢eIJB4^Èc2‘eÍQIJsc¬eĦX[chQà No
5HOLJLRXV0LQRULW\4XRWD0HGLFDO'HQWDORQO\
/LQJXLVWLF0LQRULW\4XRWD0HGLFDO'HQWDORQO\ No
Are you ward of NRI ? (Medical / Dental only) No

Ļ¯lsbIJsc¬eĦ`D
Special Category Reservation :
42D®ltB^ÍScÒ\iV
Nature of Disability:

Study Details
ci´şe¬lsĝUĻ­ec ®eÍc2DS ®eÍc2DS ®eÍc2DS ŸlsDœl©eS`b
Name and Address of the School Q\DĦD_… ¤eÎ\2ıB`b li£l[`b Year Of
Class Studied Year of Study Year of Passing
from Study To
Anitha Convent School NES street Malavalli 1 2009 2010 2010
Mandya, 571430
Anitha Convent School NES street Malavalli 2 2010 2011 2011
Mandya, 571430
Anitha Convent School NES street Malavalli 3 2011 2012 2012
Mandya, 571430
Anitha Convent School NES street Malavalli 4 2012 2013 2013
Mandya, 571430
Sri ChamSugar School Bharathinagar Maddur 5 2013 2014 2014
Mandya 571422
Sri ChamSugar School Bharathinagar Maddur 6 2014 2015 2015
Mandya 571422
Sri ChamSugar School Bharathinagar Maddur 7 2015 2016 2016
Mandya 571422
Sri ChamSugar School Bharathinagar Maddur 8 2016 2017 2017
Mandya 571422
Sri ChamSugar School Bharathinagar Maddur 9 2017 2018 2018
Mandya 571422
Sri ChamSugar School Bharathinagar Maddur 10 2018 2019 2019
Mandya 571422
Anikethan PU college Mandya 11 2019 2020 2020
571402
Bharathi composite PU college Bharathinagar 12 2020 2021 2021
Maddur Mandya 571422

¤e`ĦĻ`\D_…Payment Details
4ĝah^´Appno 2021029471 ²lc\hName

4ĝah^´Application Fees 500 ¦eÍ2Ń²lc\hBank Name Bill desk

Bank Charges Bank Ref Number VUP20048990415

Your application is allowed subject to final decision in W.P.No.

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 Final Copy Edited

Appln No:
2021029471
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eUiUhĸsĦ[
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.
¤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.

ŪsbB\cĿ 4YÍħ[cĿ
Signature of the Parent Signature of the
/ Guardian Candidate

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