GOVERNMEIYT OF KARNATAKA

SOCIAL WELFAR.E DEPARTMENT

Applicant
PRE-EXAMINATION COACHING FOR Photo
ssc-2023-24.
Details of the Applicant
Note: Caldidates are requested to fill the below particulars without fail.
Have you already taken
coaching from PETC (Please
1 mention the Course i.e.
UPSC/KAS/croup-C/
Banking/ RRB / SSC / Judiciary.
2 Register Number

Name of the Candidate

lI-[
4 Name of the Course Selected

5 Name of the Caste

6 Caste RD No

7 Annua-l Income

8 Income RD No

I SSLC Registration No.

D D M M Y Y Y Y
10 Date of Birth

Marks obtained Total Marks %

11
Graduation Details with
Percentage

l2 Aadhaar No

Score obtained in the entrance

13
exam conducted by KEA
Reservation Claim (Please
G.M P.H Hostel KRIES Women
mention-GM / Physically
t4 Challenged / Hosteller/KRIES Alemari/
School/Women/ Safai S.K Are PleaseTick(i)
Karmachari /Alemari-Are alemari
alemari)
15 Mobile No

16 Sigrature of the Candidate

 FOR OFFICE USE ONLY

1 SSLC Registration No.

Marks obtained Total Marks Percentage

2

3
Degree Percentage

Reservation Claimed
II IIITIII
Remarks of Verifying Approved
4
Officer/ Staff
/ Rejected

Date: Sig:nature of Verifying Officer

Place: Name :

Designation