Final Copy Appln No:

2021064766
5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details
4YÍħ[²lc\hCandidate Name : LAVANYA V

Q2¡l[²lc\hFather Name VENKATESH

Ÿeĵ[²lc\hMother Name SARASWATHI C N

dhġ¾SĨ£e2BDate of Birth 01/08/2002

Ĺ2DGender Female

ū¦ltşc2‘lÍMobile Number XXXXXXXXXX

6ijsşEmail XXXXXXXXXXXXXXXX

ªeĽĄs[ŸlNationality Indian

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

Ļ­ecAddress #6 THIGALARAPALYA MAIN ROAD BALAJI NAGAR NEAR
RNVK SCHOOL,PEENYA 2ND STAGRE
ªeIÍState KARNATAKA

ĝ¬lÐDistrict BENGALURU URBAN

Ÿe^iÐBhTaluk BENGALURU NORTH

īŖlisŏPin Code 560058

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&nbsp;
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
Printed Date: 20-06-2021 10-24-43 Page No: 1
 Final Copy Appln No:
2021064766
e¬lsIhVΐe\College Type UN-AIDED COLLEGE
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 BENGALURU URBAN
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 2020AN8360391
ŸlsDœl©eS`bYear of Passing 2021
4YÍħ<Ť<Ť<şľ£lsQ\DĦ£lis2Sĥc2‘lÍ
¨eeÕ؏ŏVΐe\ 20190820103
Candidate S S L C/ 10th standard Register Number (as per markscard)
ľ6ġ\VĸsďecÄ_ūS^5S͟l BENGALURU
Exam Place for CET-2021 - First Priority
ľ6ġ\VĸsďecÄ_<\N£ls5S͟l NELMANGALA
Exam Place for CET-2021 - Second Priority
BjĽlisše4ģ[ĹÐIJsc¬eĦVœl[^hĪs`ƒ4dªeĖĨÅsªe! Yes
$UH\RXHOLJLEOHWRFODLPUHVHUYDWLRQXQGHU$JULFXOWXULVW4XRWD"
BjĽ¤eÎŴsĖBVĸsďl’l²eIªeD^hcÄ_ College of Agriculture, UAS, GKVK,
Place to appear for Agriculture Practical Exam Bangalore

Reservations
TZReligion Hindu
Religion Group

—eĦ[²lc\hName of the Caste BANAJIGA SHETTY

IJsc¬eĦ`DReservation category Category-2A
—eĦVΨePVQÎ5ģc2‘lÍ RD0038191349831
&DVWH&HUWLILFDWH5'1XPEHU
®eĽB5¡e[Annual Income 70000
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD Number RD0038191349831
¨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

Printed Date: 20-06-2021 10-24-43 Page No: 2

 Final Copy Appln No:
2021064766
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
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 SPORTS
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
ST ANN'S CONVENT 1 2009 2010 2010
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 2 2010 2011 2011
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 3 2011 2012 2012
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 4 2012 2013 2013
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 5 2013 2014 2014
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 6 2014 2015 2015
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091

Printed Date: 20-06-2021 10-24-43 Page No: 3

 Final Copy Appln No:
2021064766
ST ANN'S CONVENT 7 2015 2016 2016
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 8 2016 2017 2017
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 9 2017 2018 2018
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
ST ANN'S CONVENT 10 2018 2019 2019
81 18TH CROSS TIGALARAPALYA MAIN
ROAD, 2ND STAGE PEENYA
BENGALURU,BENGALURU NORTH DT,
BENGALURU 560091
OM SAI PU COLLEGE 11 2019 2020 2020
MAGADI ROAD SUNKADAKATTE
BANGALORE 560091
OM SAI PU COLLEGE 12 2020 2021 2021
MAGADI ROAD SUNKADAKATTE
BANGALORE 560091

¤e`ĦĻ`\D_…Payment Details
4ĝah^´Appno 2021064766 ²lc\hName

4ĝah^´Application Fees 250 ¦eÍ2Ń²lc\hBank Name Bill desk

Bank Charges Bank Ref Number VUR20055333679

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 :

Printed Date: 20-06-2021 10-24-43 Page No: 4

 Final Copy Appln No:
2021064766
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

Printed Date: 20-06-2021 10-24-43 Page No: 5