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18. Are you an INDIAN National ?
19. Native State Code
Yes
No
19. a. If ‘01’ i.e., KARNATAKA, indiacate the District Code
20. Code of the State where appeared for 2nd PUC or 12th Standard or equivalent Exam
19. b. Taluk Code
20. a. If KARNATAKA District Code
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21. Are you a son / daughter of Jammu & Kashmiri Migrant?
Yes No
23. If you are claiming a seat under Special categories such as NCC, SPORTS, etc, write the CODE/S
22. Code of the place where you like to attend the CET 2011 counseling?
P Q R
Bangalore Belgaum Chittradurga Gulbarga
1
T
2
U
Hubli Mangalore Shimoga
5
3
V
4
W
6 7
FOLD ALONG THIS LINE st
th
24. STUDY DETAILS : From 1 standard to PUC / 12 standard/ Qualifying Examination
Complete Name & Address of the School / College
Classes Studied
Year of Study From To
Year of passing
st
1 Standard 2nd Standard 3rd Standard 4th Standard Telephone Number of the Institution with STD Code: 5th Standard th 6 Standard th 7 Standard
Telephone Number of the Institution with STD Code: 8th Standard 9th Standard 10th Standard Telephone Number of the Institution with STD Code: 11th Standard 12th Standard Telephone Number of the Institution with STD Code:
25. If you have appeared for Karnataka CET in the Previous years and selected a seat, then mention the seat selection particulars such as Year of appearance, CET Number, Name of the College and Course selected, etc.:
DECLARATION We declare that the above information is true and correct to the best of our knowledge and belief. We have gone through the Instructions given in the ‘CET’ 2011 brochure. In case any of the above information is found to be false or incorrect, we shall forfeit the claim to be considered or a seat selected and allotted by KEA. We are also liable for civil and criminal action, as the State Government or the KEA may take against us in this regard.
Signature of Father or Mother
NOTE : 1. Before
LEFT HAND THUMB IMPRESSION OF THE CANDIDATE
Signature of the Candidate Date : / / 2011
submitting this filled application form, please take a photocopy and keep it with you for all future references. 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.