Government of Karnataka

Karnataka Examinations Authority

Common UG Online Application - 2024
2024

2024-25 2

BPO
Common Online Common Application for Engineering, Naturopathy & Yoga, Veterinary, B. Pharma, 2nd year B.Pharma and Pharma-D, Farm
Science courses [B.Sc. (Hons) Agriculture, B.Sc. (Hons) Sericulture etc.,], and B.Sc. (Nursing) courses [including Architecture, Medical, Dental,
Ayurveda, Unani, Homoeopathy, B.P.T., B.Sc. Allied Health Sciences, BPO courses] for the Year 2024-25

Final Copy Appln No:

49202218142007

Online Application Form

I.General Details

Candidate Name : DEEPAK BASAPPA MOTEBENNUR

ತಂದ Father Name/Guardian Name BASAPPA

Mother Name POOJA

ಂ Date of Birth 02-03-2006

ಂ Mobile Number & Email 70XXXXXX11 - d****r@g****l.com

Candidate Nationality INDIAN - Resident of India

ಂ Candidate Gender MALE

Candidate Address CHAVADI ROAD BYADGI, BYADGI, HAVERI,

KARNATAKA - 581106
Caste Reservation Claimed / Income Details

Religion HINDU

Reservation category - GM -
Name of the Caste

ತ ಂ
Caste Certificate RD Number
ದ ತ ಂ Income Certificate RD
Number
Annual Income

Other Reservation claimed Details

RELIGIOUS MINORITY NO
LINQUISTIC MINORITY 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

Printed Date: 10-06-2024 12-33-30 Page No: 1

 Government of Karnataka
Karnataka Examinations Authority
Common UG Online Application - 2024
2024

2024-25 2

BPO
Common Online Common Application for Engineering, Naturopathy & Yoga, Veterinary, B. Pharma, 2nd year B.Pharma and Pharma-D, Farm
Science courses [B.Sc. (Hons) Agriculture, B.Sc. (Hons) Sericulture etc.,], and B.Sc. (Nursing) courses [including Architecture, Medical, Dental,
Ayurveda, Unani, Homoeopathy, B.P.T., B.Sc. Allied Health Sciences, BPO courses] for the Year 2024-25

Final Copy Appln No:

49202218142007
NRI-WARD NO

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

ತೃ ಭ ಷ Mother Tongue KANNADA

Do you write/appearing Board Exam of 12th in Karanataka? Yes
ಂ ಂ ತ 12
Total number of years of study in Karnataka (From 1st to 12th Std.)
ಂ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam & Qualifying Examination Board
College Type AIDED COLLEGE
ಂ KARNATAKA ( STATE BOARD )
State of 2nd PUC / 12th/ Equivalent exam & Qualifying Examination Board
District of 2nd PUC/12th/Equivalent exam (if studied in karnatka) MANGALURU (DAKSHINA
KANNADA)
ದ ಂ PUC Student Number & Year of 2023ss00150028 - 2024-
Passing
ಂ NO - 202218142007

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

Number
ಂತ ಂ NO

Have you Appeared for NEET Exams before 2023? / CET Number / Year of
appearance

Applied Courses
UG - CET Enggineering/Nursing/Veternary/Yoga & Naturopathy/Agriculture/Pharmacy
UG- Medical/Dental & Ayush (UG NEET)
UG - Para Medical Courses(BPO/BPT & AHS)
UG Architecture (NATA)

Agriculture Exam Centers

Fisheries College, Matshya nagar, Mangalore
Exam Centers
Exam Center (Priority 1) PUTTUR

Printed Date: 10-06-2024 12-33-30 Page No: 2

 Government of Karnataka
Karnataka Examinations Authority
Common UG Online Application - 2024
2024

2024-25 2

BPO
Common Online Common Application for Engineering, Naturopathy & Yoga, Veterinary, B. Pharma, 2nd year B.Pharma and Pharma-D, Farm
Science courses [B.Sc. (Hons) Agriculture, B.Sc. (Hons) Sericulture etc.,], and B.Sc. (Nursing) courses [including Architecture, Medical, Dental,
Ayurveda, Unani, Homoeopathy, B.P.T., B.Sc. Allied Health Sciences, BPO courses] for the Year 2024-25

Final Copy Appln No:

49202218142007
Exam Center (Priority 2) MANGALURU (DAKSHINA KANNADA)

Study Details
ಂ

Name and Address of the District ತ Passed Passed Board Area Medium
School and Address Class Year
ST JOHN VAINNEY HIGHER HAVERI 1 2013 KARNATA - -
PRIMARY KA (
SCHOOL,BYADAGI, STATE
BYADAGI, HAVERI BOARD )
ST JOHN VAINNEY HIGHER HAVERI 2 2014 KARNATA - -
PRIMARY KA (
SCHOOL,BYADAGI, STATE
BYADAGI, HAVERI BOARD )
ST JOHN VAINNEY HIGHER HAVERI 3 2015 KARNATA - -
PRIMARY KA (
SCHOOL,BYADAGI, STATE
BYADAGI, HAVERI BOARD )
NAVA CHAITANYA HAVERI 4 2016 KARNATA - -
VIDYALAYA BYADAGI,AT KA (
POST NEHARU NAGAR STATE
BYADAGI BOARD )
NAVA CHAITANYA HAVERI 5 2017 State URBA Kannada
VIDYALAYA N
BYADAGINEHARU NAGAR
BYADAGI
SSSLS VIDYAKENDRA MANGALURU 6 2018 State RURA English
ALIKESSSLS VIDYAKENDRA L
ALIKE 9449663239
SSSLS VIDYAKENDRA, MANGALURU 7 2019 CBSE RURA English
ALIKESSSLS L
VIDYAKENDRA, ALIKE
SSSLS VIDYAKENDRA, MANGALURU 8 2020 CBSE RURA English
ALIKESSSLS L
VIDYAKENDRA, ALIKE
SSSLS VIDYAKENDRA, MANGALURU 9 2021 CBSE RURA English
ALIKESSSLS L
VIDYAKENDRA, ALIKE
SSSLS VIDYAKENDRA, MANGALURU 10 2022 CBSE RURA English
ALIKESSSLS L
VIDYAKENDRA, ALIKE

Printed Date: 10-06-2024 12-33-30 Page No: 3

 Government of Karnataka
Karnataka Examinations Authority
Common UG Online Application - 2024
2024

2024-25 2

BPO
Common Online Common Application for Engineering, Naturopathy & Yoga, Veterinary, B. Pharma, 2nd year B.Pharma and Pharma-D, Farm
Science courses [B.Sc. (Hons) Agriculture, B.Sc. (Hons) Sericulture etc.,], and B.Sc. (Nursing) courses [including Architecture, Medical, Dental,
Ayurveda, Unani, Homoeopathy, B.P.T., B.Sc. Allied Health Sciences, BPO courses] for the Year 2024-25

Final Copy Appln No:

49202218142007
SATHYASAI LOKASEVA PU MANGALURU 11 2023 STATE RURA -
COLALIKE L
SATHYASAIVIHAR DK DT
574235
SATHYASAI LOKASEVA PU MANGALURU 12 2024 STATE RURA -
COLALIKE L
SATHYASAIVIHAR DK DT
574235
Bank Details
Account Holder deepak basappa motebennur Bank Name state bank of india
Name
IFSC Code sbin0040126 Bank Branch byadgi
Account Number 41XXXXXX690

Payment Details
AppNo 49202218142007 Bank Ref No. YHD42228363472
Application Fee Rs. 600 Bank Name Bill desk
Paid Date 08/02/2024

Uploaded Documents List

SSLC/10th standard Marks Card or equivalent Certificate
Passport Size Photo
Thumb Photo
Signature

1 ಂ ಂತ ಂ ಂ ದ ಂ ಂ

2 ಂ ತ ದ ತ ತ
ದ ಂದ ಂ ಂತ ದ
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.

Declaration

Printed Date: 10-06-2024 12-33-30 Page No: 4

 Government of Karnataka
Karnataka Examinations Authority
Common UG Online Application - 2024
2024

2024-25 2

BPO
Common Online Common Application for Engineering, Naturopathy & Yoga, Veterinary, B. Pharma, 2nd year B.Pharma and Pharma-D, Farm
Science courses [B.Sc. (Hons) Agriculture, B.Sc. (Hons) Sericulture etc.,], and B.Sc. (Nursing) courses [including Architecture, Medical, Dental,
Ayurveda, Unani, Homoeopathy, B.P.T., B.Sc. Allied Health Sciences, BPO courses] for the Year 2024-25

Final Copy Appln No:

49202218142007

ಂತ ತ ಂ
ತಂ ಂ ಂ ಂ
ತಂ ಂ ಂ ಂ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

Signature of the
Candidate
Candidate

Printed Date: 10-06-2024 12-33-30 Page No: 5