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    Keaapplicationpd 3920170499746 07112022 174827

    Uploaded by

    Gagan Gowda V

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Keaapplicationpd 3920170499746 07112022 174827

    Uploaded by

    Gagan Gowda V
    27 views3 pages

    Original Title

    keaapplicationpd_3920170499746_07112022_174827

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    27 views3 pages

    Keaapplicationpd 3920170499746 07112022 174827

    Uploaded by

    Gagan Gowda V

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Final Copy Appln No:

    3920170499746

    5Ŗ¬ltŖ4ĝOnline Application Form

    I.General Details

    Applied For M B A (only)

    4YÍħ[²lc\hCandidate Name : PRIYANKA S

    Q2¡l[²lc\hFather Name/Guardian Name SUNDARAIAH S

    Ÿeĵ[²lc\hMother Name MANJULA

    dhġ¾SĨ£e2BDate of Birth 30/07/2001

    Ĺ2DGender FEMALE

    ū¦ltşc2‘lÍMobile Number 90XXXXXX09

    6ijsşEmail P****3@g****l.com

    ªeĽĄs[ŸlNationality INDIAN

    4YÍħ[c2VBS42•lĻ­ecCandidate's Postal Address for Communication

    Ļ­ecAddress NO 2 2ND CROSS 2ND MAIN NEW GUDDADAHALLI MYSORE


    ROAD BANGALORE
    ªeIÍState KARNATAKA

    ĝ¬lÐDistrict BENGALURU URBAN (BANGALORE URBAN)

    Ÿe^iÐBhTaluk BENGALURU NORTH

    īŖlisŏPin Code 560026

    Academic Details
    lisšeQuota claimed KARNATAKA

    4dŸeb\QhÐlisŏEligibility Clause Code CLAUSE - A


    Īs`ƒB£eLBªeIÍSB£eLBVĸsďeZ2NĺUœlch`<Ť<Ť<şľVĸsďl[ĹÐ YES
    ŸlsDœl©eĖ\hĻªls!
    Completed SSLC from KSEEB, Govt. of Karnataka?
    Candidate SSLC/10th standard Registration Number (as per markscard) 20170499746
    ľ6ġ\VĸsďecÄ_ūS^5S͟l BENGALURU (BANGALORE )
    Exam Place for CET-2022 - First Priority
    ľ6ġ\VĸsďecÄ_<\N£ls5S͟l MYSURU (MYSORE)
    Exam Place for CET-2022 - Second Priority
    Caste/ Income

    TZReligion HINDU
    —eĦ[²lc\hName of the Caste ADI KARNATAKA
    IJsc¬eĦ`DReservation category SC

    Printed Date: 07-11-2022 05-48-27 Page No: 1


    Final Copy Appln No:
    3920170499746

    —eĦVΨePVQÎ5ģc2‘lÍ RD0039267486906
    &DVWH&HUWLILFDWH5'1XPEHU
    5¡e[VΨePVQÎ5ģc2‘lÍIncome Certificate RD Number RD5019267398595
    ¨eQj§e°lMother Tongue KANNADA
    Annual Income 95000

    Study Information

    Qualifying Degree status? Appreared University seat No:(USN) 19AUC41367


    Qualifying Degree Collage Government First Grade Qualifying Degree Bangalore University
    Name? College University Name?

    Total Number of Years of Study in Karnataka : 12


    Qualifying Degree / Engineering Branch Bcom(3 Years) - Commerse Degree

    Particular of Result Month Passing Year of Passing Maximum Marks Secured Marks
    Examination
    1 Pass SEP 2020 1500 1204
    2 Pass SEP 2021 1700 1205
    3 Result Await 0 0 0 0

    Reservation
    EX-DEFENCE NO
    KALYANA KARNATAKA RESERVATION NO

    M.TECH Program Details(Only for M.TECH Candidate)


    PGCET Appering under: M B A (only)
    PGCET EXAM Appering course name: MBA
    Have appered for gate during 2020 to 2022? No
    GATE code N/A
    GATE Score 0
    Do you claim seat under sponserd quota? No
    GATE Subject Name
    GATE Marks out of 100 0.00

    Payment Details
    AppNo 3920170499746 Bank Ref No. YUP21508595893
    Application Fee Rs. 400 Bank Name Bill desk
    Printed Date: 07-11-2022 05-48-27 Page No: 2
    Final Copy Appln No:
    3920170499746

    Paid Date 18/10/2022

    ęisbžlDeclaration

    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eUiUhĸsĦ[
    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.

    ¤eÎ2ah¤e^\D—lšlŏ5ĬscŝcĿPrincipal / Gazetted Officer Signature


    ²lc\hName :

    V†PcĿSignature :

    ūd\hSeal:

    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.

    20/10/2022

    Declared Date 4YÍħ[cĿ


    Left hand Thumb of
    Candidate Signature of the
    Candidate

    Printed Date: 07-11-2022 05-48-27 Page No: 3

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