Government of Karnataka

Karnataka Examinations Authority

೨೦೨೪ -೨೫
Online Application for Lateral Entry Engineering for the Year 2024-25

Final Copy Appln No:

3920210137629

Online Application Form

I.General Details

Candidate Name : TARUN S

ತ ದ Father Name/Guardian Name SHANMUKAPPA

Mother Name SHARADA

Date of Birth 03-07-2004

- Mobile Number & Email 80XXXXXX62 - t****i@g****l.com

Candidate Nationality INDIAN -

Candidate Gender MALE

Spouse Name if Married

Candidate Address NAGENDARNMATTI 3RD WARD HAVERI, HAVERI,

HAVERI, KARNATAKA - 581110
Caste Reservation Claimed / Income Details

Religion HINDU

- Reservation category - Name of the Caste SC - VADDAR

ತ RD1218478026124
Caste Certificate RD Number
ದ ತ Income Certificate RD Number RD1218478026126

Annual Income 35000

Other Reservation claimed Details

PH (DIFFERENTLY ABLED) YES Orthopaedic/Locomo
tar
STUDY IN KANNADA MEDIUM FROM 1 TO 10TH NO
STUDY IN RURAL AREAS FROM 1 TO 10TH NO
KALYANA KARNATAKA (371 (J)) NO

Academic Details
Quota claimed / ತ Eligibility Clause Code - CLAUSE - A

Printed Date: 03-07-2024 09-09-17 Page No: 1

 Government of Karnataka
Karnataka Examinations Authority

೨೦೨೪ -೨೫
Online Application for Lateral Entry Engineering for the Year 2024-25

Final Copy Appln No:

3920210137629

ತೃ ಭ ಷ Mother Tongue KANNADA

Qualification Diploma
Diploma ತ ) 13
Total number of years of study in Karnataka (From 1st to Final Year
Diploma.)
Diploma - DIPLOMA IN COMPUTER SCIENCE
Branch of Studied in Diploma / Equivalent Qualifying Examination AND ENGINEERING
College Type GOVT. OF KARNATAKA
Diploma - BOARD OF TECHNICAL
Board of Diploma / Equivalent / Qualifying Examination Board EDUCATION, BANGALORE
District of DIPLOMA /Equivalent exam (if studied in karnatka) HAVERI
Diploma ದ 185cs21030 - 2024-
Diploma / Equivalent Student Number & Year of Passing
YES - 20210137629

Completed SSLC from KSEEB, Govt. of Karnataka? and Registration

Number
ತ NO

Have you Appeared for CET Exams before 2023? / CET Number / Year of
appearance
Are You Completed in Lateral Entry?

Applied Courses
Diploma CET Lateral entry Engineering

Exam Centers
Exam Center (Priority 1) DAVANGERE
Exam Center (Priority 2) DAVANGERE

Printed Date: 03-07-2024 09-09-17 Page No: 2

 Government of Karnataka
Karnataka Examinations Authority

೨೦೨೪ -೨೫
Online Application for Lateral Entry Engineering for the Year 2024-25

Final Copy Appln No:

3920210137629

Study Details

Name and Address of the District ತ Passed Passed Board Area Medium
School and Address Class Year
RVS HIGHER PRIMARY DAVANAGER 1 2012 KARNATA - -
SCHOOL E KA (
STATE
BOARD )
RVS HIGHER PRIMARY DAVANAGER 2 2013 KARNATA - -
SCHOOL E KA (
STATE
BOARD )
SIR M VISHWESHWARIAH HAVERI 3 2014 KARNATA - -
SCHOOLHAVERI KA (
STATE
BOARD )
SIR M VISHWESHWARIAH HAVERI 4 2015 KARNATA - -
SCHOOLHAVERI KA (
STATE
BOARD )
SIR M VISHWESHWARAIAH HAVERI 5 2016 State URBA English
SCHOOL HAVERIsir m v N
school HAVERI
SIR M VISHWESHWARAIAH HAVERI 6 2017 State URBA English
SCHOOL HAVERIsir m v N
school HAVERI
SMS HIGHER PRIMARY HAVERI 7 2018 State URBA Kannada
SCHOOL HAVERISMS NEAR N
MAGAVI TAKIJA HAVERI
HAVERI
SMS GIRLS HIGH SCHOOL HAVERI 8 2019 State URBA Kannada
HAVERISHIVAYOGESHWAR N
NAGAR HAVERI
SMS GIRLS HIGH SCHOOL HAVERI 9 2020 State URBA Kannada
HAVERISHIVAYOGESHWAR N
NAGAR HAVERI
SMS GIRLS HIGH SCHOOL HAVERI 10 2021 State URBA Kannada
HAVERISHIVAYOGESHWAR N
NAGAR HAVERI

Printed Date: 03-07-2024 09-09-17 Page No: 3

 Government of Karnataka
Karnataka Examinations Authority

೨೦೨೪ -೨೫
Online Application for Lateral Entry Engineering for the Year 2024-25

Final Copy Appln No:

3920210137629

SRI CHANNAKESHAVA HAVERI Diploma 1st 2022 KARNATA - -

GOVT POLYTECHNIC Year KA (
BANKAPUR STATE
BOARD )
SRI CHANNAKESHAVA HAVERI Diploma 2nd 2023 KARNATA - -
GOVT POLYTECHNIC Year KA (
BANKAPUR STATE
BOARD )
SRI CHANNAKESHAVA HAVERI Diploma 3rd 2024 KARNATA - -
GOVT POLYTECHNIC Year KA (
BANKAPUR STATE
BOARD )

Bank Details
Account Holder TARUN BINJADAGI Bank Name KARNATAKA VIKAS GRAMEEN
Name BANK
IFSC Code KVGB0007217 Bank Branch NAGENDARNMATTI HAVERI
Account Number 8910XXXXXX3

Payment Details
AppNo 3920210137629 Bank Ref No. YHD42327618091
Application Fee Rs. 700 Bank Name Bill desk
Paid Date 14/05/2024

Uploaded Documents List

SSLC/10th standard Marks Card or equivalent Certificate
PH (Differently abled)
Passport Size Photo
Thumb Photo
Signature
Class 1 Study Certificate
Class 2 Study Certificate
Class 3 Study Certificate
Class 4 Study Certificate

Declaration

Printed Date: 03-07-2024 09-09-17 Page No: 4

 Government of Karnataka
Karnataka Examinations Authority

೨೦೨೪ -೨೫
Online Application for Lateral Entry Engineering for the Year 2024-25

Final Copy Appln No:

3920210137629

ತ ತ
ತ
ತ ತ ದ
ತ ತ ದ

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.

Left hand Thumb of

Candidate Signature of the
Candidate

Printed Date: 03-07-2024 09-09-17 Page No: 5