B£eLBce\ Government of Karnataka

Karnataka Examinations Authority

B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_ 42Sªl(B.Sc. 5UŤ BjĽB.Sc 5UŤ 4\PÍ6ŸeÍĨ İ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e ¬eÍL\ş<2ġÎ `jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
5020217353104

5Ŗ¬ltŖ4ĝOnline Application Form

I.General Details

4YÍħ[²lc\hCandidate Name : MADIHA IRAM

Q2¡l[²lc\hFather Name/Guardian Name MOHAMED ASIFULLA KHAN

Ÿeĵ[²lc\hMother Name TANVEEN SULTANA

dhġ¾SĨ£e2BDate of Birth 20/11/2004

ū¦ltşc2‘lÍ6ijsşMobile Number & Email 94XXXXXX52 - m****4@g****l.com

4YÍħ[ªeĽĄs[ŸlCandidate Nationality INDIAN

4YÍħ[Ĺ2DCandidate Gender FEMALE

4YÍħ[Ļ­ecCandidate Address 504,5TH CROSS,H.M.T LAYOUT,CBI

ROAD,BANGALORE-560032, BENGALURU NORTH,
BENGALURU URBAN, KARNATAKA - 560032
ľ6ġ\VĸsďecÄ_ūS^5S͟l BENGALURU NORTH
Exam Place for CET-2023 - First Priority
ľ6ġ\VĸsďecÄ_<\N£ls5S͟l BENGALURU SOUTH
Exam Place for CET-2023 - Second Priority
BjĽlisše4ģ[ĹÐIJsc¬eĦVœl[^hĪs`ƒ4dªeĖĨÅsªe! NO
Are you eligible to claim reservation under
$JULFXOWXULVW4XRWD"
BjĽ¤eÎŴsĖBVĸsďl’l²eIªeD^hcÄ_
Place to appear for Agriculture Practical Exam
Caste Reservation Claimed / Income Details

TZReligion MUSLIM

IJsc¬eĦ`D—eĦ[²lc\hReservation category - GM - GENERAL

Name of the Caste
—eĦVΨePVQÎ5ģc2‘lÍ
&DVWH&HUWLILFDWH5'1XPEHU
5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD
Number
Annual Income 1000000

Other Reservation claimed Details

NCC NO
SPORTS NO
SCOUTS & GUIDES NO
DEFENCE NO

Printed Date: 06-04-2023 08-34-17 Page No: 1

 B£eLBce\ Government of Karnataka
Karnataka Examinations Authority
B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_ 42Sªl(B.Sc. 5UŤ BjĽB.Sc 5UŤ 4\PÍ6ŸeÍĨ İ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e ¬eÍL\ş<2ġÎ `jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
5020217353104
EX-DEFENCE (ONLY FOR KARNATAKA) NO
PH (DIFFERENTLY ABLED) NO
ANGLO-INDIAN NO
CENTRAL ARMED POLICE FORCE NO
EX-CENTRAL ARMED POLICE FORCE NO
STUDY IN KANNADA MEDIUM FROM 1 TO 10TH NO -
STUDY IN RURAL AREAS FROM 1 TO 10TH NO -
JAMMU & KASHMIR MIGRANTS NO -
KALYANA KARNATAKA (371 (J)) NO -

Academic Details
lisšeQuota claimed / 4dŸeb\QhÐlisŏEligibility Clause Code KARNATAKA - CLAUSE - A

¨eQj§e°lMother Tongue URDU

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 
£lsī[hľ£lsVĸsďl[ªeIÍ4dŸeVĸsďeZ2Nĺ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam & Qualifying Examination Board
e¬lsIhVΐe\College Type PRIVATE
£lsī[hľ£lsVĸsďl[ªeIÍ4dŸeVĸsďeZ2Nĺ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam & Qualifying Examination Board
District of 2nd PUC/12th/Equivalent exam (if studied in karnatka) BENGALURU URBAN
ī[hľĻ¡eÍħc2‘lÍŸlsDœl©eS`bPUC Student Number & Year of 2022an00110618 - 2023
Passing
Īs`ƒB£eLBªeIÍSB£eLBVĸsďeZ2NĺUœlch`<Ť<Ť<şľVĸsďl[ĹÐ NO - 20217353104
ŸlsDœl©eĖ\hĻªls!
Completed SSLC from KSEEB, Govt. of Karnataka? and Registration
Number
Īs`ƒĔ´2QūS^hľ6ġĪsō£ešeVĸsďlDĺ’l²eIªeĖĨÅsªe!ľ6ġVήlsa NO
ġlōc2‘lÍVĸsďlXªlS`b
Have you Appeared for CET / NEET / NATA Exams before 2023? / CET
Admission Ticket Number / Year of appearance

Study Details
ci´şe¬lsĝUĻ­ec ®eÍc2DS

Name and Address of the School and Address District Q\DĦD_ Passed `bPassed
Class Year
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 1 2012
BANGALORE-560001

Printed Date: 06-04-2023 08-34-17 Page No: 2

 B£eLBce\ Government of Karnataka
Karnataka Examinations Authority
B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_ 42Sªl(B.Sc. 5UŤ BjĽB.Sc 5UŤ 4\PÍ6ŸeÍĨ İ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e ¬eÍL\ş<2ġÎ `jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
5020217353104
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 2 2013
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 3 2014
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 4 2015
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 5 2016
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 6 2017
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 7 2018
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 8 2019
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 9 2020
BANGALORE-560001
SOPHIA HIGH SCHOOL, 70, PALACE ROAD, BENGALURU NORTH 10 2021
BANGALORE-560001
MOUNT CARMEL PU COLLEGE, 58, ABSHOT BENGALURU NORTH 11 2022
LAYOUT, VASANTH NAGAR, BANGALORE-560052
MOUNT CARMEL PU COLLEGE , 58, ABSHOT BENGALURU NORTH 12 2023
LAYOUT,VASANTH NAGAR, BANGALORE-560052

Payment Details
AppNo 5020217353104 Bank Ref No. YHD41828086459
Application Fee Rs. 500 Bank Name Bill desk
Paid Date 06/04/2023

DZĪľ1<¬eÐVÎĔÎĶV†P’li2NU2Q\4YÍħ[h42ĦZVÎĦ[UhÇZhĨÎľli2Nh¡eC¬l œeBhÍij2ō Vĸļs^£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.

ęisbžlDeclaration

Printed Date: 06-04-2023 08-34-17 Page No: 3

 B£eLBce\ Government of Karnataka
Karnataka Examinations Authority
B£eLBVĸsďe¤eÎĩe\ Common Entrance Test - 2023
±e¨eUÍVήlsaVĸsďlzxz{

2023-24£ls±eĹUūS^£l[`bS62ĝĪ[ĸ2Ņ5ĔšlB¹ŝŴsDZQhãeÍGhªlisVĦVah®ltSÍĔs[ZQhÃVahc2’lisV£lBjĽĻĐeU
lisŤD_ 42Sªl(B.Sc. 5UŤ BjĽB.Sc 5UŤ 4\PÍ6ŸeÍĨ İ¥e¨e¥e¨eģ2£ls`bSİ¥e¨e ¬eÍL\ş<2ġÎ `jĦÃV\
lisŤD_Vήlsal´5Ŗ¬ltŖZi^B4ĝ
Online Application for Admission to First Year Engineering / Architecture / Yoga & Naturopathy / Veterinary / Farm Scinces B.Sc. (Hons)
Agriculture / B.Sc. (Hons) Forestry etc) / B. Pharma / Pharma-D/ 2nd Year B-Pharma (Lateral Entry) Professional Courses for the Year 2023-24
Appln No:
Final Copy
5020217353104
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.

06/04/2023
4YÍħ[cĿ
Left hand Thumb of Declared Date
Signature of the
Candidate
Candidate

Printed Date: 06-04-2023 08-34-17 Page No: 4