Confirmation Copy [225065] APP No: 225065

t!Jr::f dJJr::f ~~f Online Application Form

1.Student Information
~?3f" cdoaj6 Application Number 225065

I .1. ~?;l61l1f"(ili
~cdd> Candidate Name JANAVI S

I .2. ~ot:fai> ~cdd> Father Name J SATHEESH

I .3. ~dbai> ~cdd> Mother Name SHALINI G S

I.4.iIDq.d f:)~oe Date of birth: 31-01-2003

r.s.eer: Gender: Female

1.6. ~?;l61l1f"ai>
cdoc5e1f"drjJ;,d~V' cdoaj6 XXXXXX5014 I. 7. OiIcl!f~ai>~ Indian
Candidate Contact Mobile Number: Nationality

1.8. ~.c;1)eV' c:l~cd E-Mail-Id : satheXXX

1.9. e~tSfPf(m iI:loa1~flj ~o?J ~\r.);u Candidate's Postal Address for Communication

c:l~cd NO 1250/15/6A 1ST MAIN ROAD 1ST CROSS, K S TOWN, BANGALORE,

BENGALURU SOUTH, BENGALURU URBAN (BAN GALORE URBAN), KARNATAKA
Address:
- 560060
9 (f) c5ainf"ai> rjJ;,d~V' cdoa16 XXXXXX3614
Alternative Mobile Number:

1.1O. &o~@ cj~fnoJ .t~(Ja1e(~ ~cjd. Details of Appearing Previous CET Exams

I .1 O(a). ~e~ &of:)c;:jrjilif"rlvq CET I NEET I NATA c56esai>~ ~rtd.>f!/;)ot\~eOil ? No

Have you appeared for previous CET I NEET I NATA Exam?

II Reservation Details
1l.1. ~c5f"~ eot\d ~~tf ~~ ~abo c:mt\ Eligibility Clause Code: a

11.2. rti<:i>f"
Religion: Hindu

II .3. c:m~ Qija (idICloV'

I ~d~?d d~tff" a!J~d) KANNADA
Mother Tongue
n.4. ~e~ GJ'd GJ'd GJV'.t 110c;:f~~drl~ai>~ e~n.Jeldq m6cdorl c:mt\~eOil? Yes
Have you studied SSLC/10th standard in Karnataka?
II .5. ~~~ e~n..3edq 12 c;:f~iliI~t3'f" c56~Sai>~ t.)df:)~~OiII ~cl.t~Ot\~OiII Yes
t.)dam~f:)eOil
~o
?
Did you write/appearing/attending Board Exam of 12tb in Karnataka?
n. 6. e~f"fJedq (1 60d 12c;:f~~drl~rjdrt) m6cdorl c:mt\ ~erlf"d cMof:)d $E<lf" 12
rjamoJ.l.
Total number of completed years of study in Kamataka (From 1st to 12tb Std.)
II. 7. ~e~ l';nc:l.lf"e~~ cdom6~ c:l.lecdm~ t.)ai>itb~eOil? No
Are you claiming Religious Minority Quota ?
«j~di~eai> r;1)~ do~ (j~d6oeai> ~e~f" rl"rt c:m~ r;IDc}!or;1)~ ~~ai>i'f
only for medical and dental courses (Muslim /Cbristian)

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 Confirmation Copy [225065] APP No: 225065

II. 8. Are you claiming Linguistic Minority Quota ? No

(rj.d6~~a1>c:i>~doc! rj,\d6~ea1>~eitff" rl"rt cm~
only for medical and dental courses (Tuluffamil/felugu/Kodava)
<»t:i>~e~ tdc:il.klf!lctJc:br:l
cmc!ol~c1,ennff.3ed~ Wol6idorl
cm~d r:laf"rl~,10 ~~Wol12
~~ c!drl~a1>dQel3'f"ameS ~M ~itf ~el3' c;het1~r:lvo~c!~F\c:b~d.
Note: It depends on Mother Tounge ,Number of years study in Karnataka,
Board Exam of 10thl12thIBoth in Karnataka. and clause code 'a'
II .9. ~~a1> afidc:bName of the Caste: VOKKALIGA

II .9.(a). ~e~ ~abo cm~c:br:l ~eiduw~ r:lrlf" Category-3A

Reservation category you have selected :
II .9.(b). Caste Certificate RD Number
II .9.(c). Income Certificate RD Number
11.10.a>f.l>oe.>d
~~f"e r:ldcmtd t;;l~ c:il.klvrl"od ~.rlY~ 1000000
Annual Income of the family from all sources in Rupees:
II.It. ~f.keu' 371 (J) af.dcm.1.c:f-~nnf"f.3~~eEnd~a1>~ ~eidcn~ c:!da1>w~i!lf"6c:bc:l~? No
Are you claiming reservation under Article 371 (J) Hyderabad Karnataka ?
II 12. ~e~ 1 60d 10~e c!drl~a1>r:ldrtennf"f.3ed l1!!~e~ c;de~d~ ~6idorl cm~~e~? No
Have you studied in Rural area of Karnataka from 1st to 10th standard?
II .13. ~e~ 1 60d 10~e c!drl~a1>r:ldrte~~ cmQ6c:i>d~~6idorl cm~~e~? No
Have you studied in Kannada Medium from 1st to 10th standard?
11.14. .,j~eii .,j,)e~mc!cjrlr Special Category Reservation: I
11.15. ~e~ 2020 d mcmtd6 c;c:re~ameS e.>da1>w<»~iU>r:l
~Y ~abo cm~ BENGALURU (BANGALORE)
Select the 1st preference place one you wish to appear for CET -2020
Select the 2nd preference place two you wish to appear for CET-2020

Select the 3rd preference place three you wish to appear for CET·2020

11.16. ~e~ ~c:i>l

•..,.~,6 r:lvi<fmdd c:i>rllc:i>rl\f? Are you a Son/Daughter of Jammu & No
Kashmiri Migrant?

Il.I7. ame.g.> c;jcjdrlwExamination Details

1I.17(a).~i!lf"~ c:!6eS Qualifying Examination Board: Karnataka 2nd PU Science

1I.17(b). c:l~c:lm6va1>I dtilel3'f"afidc:bMention the University / Board Name:

1I.17(d).~nnff.3e ctJ~ t;;lt{f<»IctJe:>t;;lt{fctJ<»~F\~~ ~ou' afidc:bIf Karnataka CBSE / CISCE

School Name:
1I.17(e).ennrf.3e 2~e Jloh>ctJ(c:l~td) 2020d w.~f"e c:!6esrt~~~ruc:l~ ? Yes
Are you appearing for Karnataka 2nd PUC Annual Examination 2020 (Science) ?
11.17(1).Jloh>~doe.r idoa16PUC Student Number: 2019AS6910186

1l.17(g).<»t;!~d~ 3erlrdcdr.ld r:larr:l~ tdc:il.klf!lctJ

If No Enter the Year of Passing:

1I.17(i). ~e~ 2~e Jloh>ctJ/12~e I c!<.icmtdc!drl~a1>c:!6eaa1>~3rtt:i>Mo~c:br:l~~6 KARNATAKA

State where appeared for 2nd PUC/12th/Equivalent :
II.] 70). ~e~ 2~e Qoh>ctJ/12~e I c!<.icmtdc!drl~a1>c:!8eSa1>~3rtt:i>Mo~c:br:l?!~ BENGALURU URBAN
District where appeared for 2nd PUC/12th/Equivalent exam:
II.17(k). ~"ee m~6 Native State : KARNATAKA

n.17(l).~"e~ ?!~ Native District : BENGALURU URBAN (BAN GALORE URBAN)

I1.18. ~e~ eol~e~eEnd~a1>~ ~eiduw~a1>~ c:!da1>w~i!lf"8c:bc:l~?(~o:D'r id,\"'!', Met{ff"rl"rt No

cm~ ~~<nliU>~d)
Are you claiming Agriculturist Quota Reservation?

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 Confirmation Copy [225065] APP No: 225065

1I.18.a. e.,)~~cl.k>d'\e a6e~ eeo~

Agriculture Practical Exam Centre:

III . WtlocUorl
c:lcjdrl'ch: 1 i\Je<!drl~oj)od c!lom,t /12i\Je <!drl~ / ~c5f~ al6egabcjdr1
STUDY DETAILS: From 1st standard to II PUC I 12th standard I Qualifying Examination
~oU' I ~dctl~ .:l~cO c:il~ dJ<ld<JdclcOo~6 <Jd6cOorid W.6cOorid W.6cOorid ~crifrjamd
Complete Name & Address of the School I College with <!dri~ri'ct.l ~dot;)e<:.iaf dJ<><d ail <:.iaf <:.iaf
Telephone Number
Classes Year of study Year of Year of
Studied From study To Passing

FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 1 2008 2009 2009

08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 2 2009 2010 2010
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 3 2010 2011 2011
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 4 2011 2012 2012
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 5 2012 2013 2013
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 6 2013 2014 2014
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 7 2014 2015 2015
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 8 2015 2016 2016
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 9 2016 2017 2017
08212491006
FLOS CARMEL! CONVENT SCHOOL MYSORE 570003 10 2017 2018 2018
08212491006
SURANA IND P U COLLEGE K S TOWN BANGALORE 560060 11 2018 2019 2019

P NO 08028486366
SURANA IND P U COLLEGE K S TOWN BAN GALORE 560060 12 2019 2020 2020

P NO 08028486366
Declaration
Q ~nf cJ~nfc:mmo<!d ~eadlcj c;;)~ i5e"drl'ch / ~PD~rl'ch @r.::brt~"dr.::b~rt cU<!6 ~a>dcjod> Q ~tld
ifiO)ri.>
~ecl;m~ecj . Q ~nf cJ~nf~~f (!)o2.).)~ddo cUo2.)oe,tdo~ ~PD~ d~c!laab~ iIiClri.> cj'Cf id~~ @~ ~eadlcj c;;)~
dc:lC;;)
~PD~/ id!<>tii\JrlY~ (!)om c;;)?4.6doj)od~edl~ecj. ~od> cjeoJ ~~ ~nf cJ~nfc:mmo<!d ~eadlcj <>ild~de ~PD~om
<!~ ~Qr;:n ~cU<!6cjod>dod> 2.)od~ d~fE3d al6e~ ~eOo)d~ Q cU02.)oQ@r.::b.~dl~ ~rtd>M~2.)i!br.:ldd 00)i\iJt)@.>

6e~ab ~r.::brl"rt 2.)~i\n"'dl~ecj.

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.

~eaed ~~f cO&I c:lr3 ~?;l6~fail c:lr3 e~~ttdoJ ri>ma, ~?;l6~fail ~~f cO&
ei ~etdoJ ri>ma, Left Hand Thumb Signature of the
impression of the Candidate Candidate
Signature of the Parent
I Guardian

Date: 21-02-2020 11:05:50

Printed Date: 23-07-202012-10-04 Page No: 3

 Confirmation Copy [225065] APP No: 225065

!DVc;uomoi> ~cjd Payment Status

~?3fmuo : 250 ~.s0e' ~iddl : online INS

Application Fees : Bank Name:
~.s0e' idoaJ.s: RUR2854461477 muo idomai> e>lViO~ : 21-02-2020
7
Bank Ref No : Date of Payment:

~o!D~vd I ri~fJt:f C5~eiU~ iUlo Principal I Gazetted Officer Signature

~iddl Name:

~E'<If id&:>Signature:

c::iJiIC!!dl Seal:
, 17 .. 'i~ Maio,
"'T" I.
• .••• U 'J
rl(j)~JJ : 1.~m crl,~,ab~E'<Ifrtlt>O{j;;Joi5d .rB?JJ~falli. ~ I<rl.~ ~. N otb mald (m~.rc:j)o~) crl6!>w~ idod?Jfd(j
ft -' -' "£P"l9~' ar emf' ,'tl4t" " ft

d~ai>mft idqidt.1(~. Bang.:t'ore.56v ':::.-

2.JJef.l) i!lota~ ~~abai> id(j)ai>dq 2.>dftid>cj~~ (j)~ ~mai> ~cmE'<l crl~~ ~rji dJ.rji ~?3fai> id(j)ai>dq ;;J~e>JJd ~~ (j)~
~mai>~ ~~ai>mft 2.>odeC5ftdt.1e~. ~o~(j) ~e~£!ai> i\!oi5d a1r.I~de ~dE'<l~o ~~ai>q r.>dmcj£!ri ~cj~~~dl~e>~.
NQIE: 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 I Category will be permitted
after the final declaration.
Details of reservation claimed by the candidate
Clause Code a Name of the Caste VOKKALIGA

10 Years Rural Study No Reservation Category Category-3A

10 Years Stury in Kannada No Article 371 (J) Hyderabad Karnataka No

Medium
AgriCUlturist Quota No J&K Migrant No

NCC No DEFENCE No ANGLO-INDIAN No

SPORTS No EX-DEFENCE No CENTRAL ARMED POLICE No

FORCE
SCOUTS & GUIDES No PH (Differently abled) No
EX-CENTRAL ARMED POLICE No
FORCE

Printed Date: 23-07-202012-10-04 Page No: 4