Appln No:

3920200345554

5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details
4YÍħ[²lc\hCandidate Name : ANEEZ HASSAN

Q2¡l[²lc\hFather Name/Guardian Name AHAMAD HASSAN

Ÿeĵ[²lc\hMother Name AVVAMMA

dhġ¾SĨ£e2BDate of Birth 07/05/2004

Ĺ2DGender MALE

ū¦ltşc2‘lÍMobile Number 74XXXXXX37

6ijsşEmail a****9@g****l.com

ªeĽĄs[ŸlNationality INDIAN

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

Ļ­ecAddress ACHAL HOUSE MALLAR VILLAGE POST KAUP UDUPI

DISTRICT
ªeIÍState KARNATAKA

ĝ¬lÐDistrict UDUPI

Ÿe^iÐBhTaluk UDUPI

īŖlisŏPin Code 574106

Īs`ƒĔ´2QūS^hľ6ġĪsō£ešeVĸsďlDĺ’l NO
²eIªeĖĨÅsªe!
Have you Appeared for CET / NEET / NATA Exams
before 2022?
ľ6ġVήlsaġlōc2‘lÍCET Admission Ticket Number

VĸsďlXªlS`b
Year of appearance
Īs`ƒľ6ġĪsō£ešeZQhÃ<Ŗ<ľÈD_ĹЩe`ƒ¡lsľsLh NO
VœlSh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 CLAUSE - A

Īs`ƒB£eLBªeIÍSB£eLBVĸsďeZ2NĺUœlch`<Ť<Ť<şľVĸsďl[ĹÐ YES
ŸlsDœl©eĖ\hĻªls!
Completed SSLC from KSEEB, Govt. of Karnataka?
Do you write/appearing Board Exam of 12th in Karanataka? Yes
B£eLBSĹÐ?Lh¾`bD_4TÍ[Uc2‘lÍ
ĸ2S£lsQ\DĦ`ªl’l 12
7RWDOQXPEHURI\HDUVRIVWXG\LQ.DUQDWDND)URPVWWRWK6WG

Printed Date: 28-08-2022 09-17-28 Page No: 1

 Appln No:
3920200345554

4dŸeVĸsďeZ2NĺQualifying Examination Board KARNATAKA ( STATE BOARD )

e¬lsIhVΐe\College Type PRIVATE
£lsī[hľ£lsc¨eUVĸsďl[ªeIÍ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam
District of 2nd PUC/12th/Equivalent exam (if studied in karnatka) UDUPI
Student of Karnataka 2nd PUC

ī[hľĻ¡eÍħc2‘lÍPUC Student Number 2021SU240232

ŸlsDœl©eS`bYear of Passing 2022
Candidate SSLC/10th standard Registration Number (as per markscard) 20200345554
ľ6ġ\VĸsďecÄ_ūS^5S͟l UDUPI
Exam Place for CET-2022 - First Priority
ľ6ġ\VĸsďecÄ_<\N£ls5S͟l MANGALURU (DAKSHINA
Exam Place for CET-2022 - Second Priority KANNADA)
BjĽlisše4ģ[ĹÐIJsc¬eĦVœl[^hĪs`ƒ4dªeĖĨÅsªe! NO
$UH\RXHOLJLEOHWRFODLPUHVHUYDWLRQXQGHU$JULFXOWXULVW4XRWD"
BjĽ¤eÎŴsĖBVĸsďl’l²eIªeD^hcÄ_
Place to appear for Agriculture Practical Exam
Caste/ Income

TZReligion MUSLIM
—eĦ[²lc\hName of the Caste MUSLIM
IJsc¬eĦ`DReservation category 2B
—eĦVΨePVQÎ5ģc2‘lÍ RD0039329310734
&DVWH&HUWLILFDWH5'1XPEHU
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD Number RD0039329310734
¨eQj§e°lMother Tongue OTHERS
Annual Income 50000

Reservation
NCC NO
SPORTS NO
SCOUTS & GUIDES NO
DEFENCE NO
EX-DEFENCE NO
PH (DIFFERENTLY ABLED) NO
ANGLO-INDIAN NO
CENTRAL ARMED POLICE FORCE NO
EX-CENTRAL ARMED POLICE FORCE NO
KANNADA NO
RURAL NO

Printed Date: 28-08-2022 09-17-28 Page No: 2

 Appln No:
3920200345554

JAMMU AND KASHMIR MIGRANTS NO

KALYANA KARNATAKA RESERVATION NO

Study Details
ci´şe¬lsĝUĻ­ec ®eÍc2DS

Name and Address of the School Q\DĦD_…Class Studied `bYear of Study To

Al ihsan academy Scho muloOr 1-10 2011-2020

Mgm Pu colLeGe udupi 11-12 2021-2022

Payment Details
AppNo 3920200345554 Bank Ref No. WHD41147759765
Application Fee Rs. 500 Bank Name Bill desk
Paid Date 15/05/2022

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.

Printed Date: 28-08-2022 09-17-28 Page No: 3

 Appln No:
3920200345554

Declared Date 4YÍħ[cĿ

Left hand Thumb of
Candidate Signature of the
Candidate

Printed Date: 28-08-2022 09-17-28 Page No: 4