1. Application Number 100296
1. Name of the Candidate : HEMANTH N C
2. Name of the Mother : NANDA BS
3. Name of the Father : CHANDRASHEKARAPPA NN
10. Religion : Hindu 11. Nationality : Indian
6. Contact Mobile Number : 9535876015 7. E-Mail-ID : hemanthyashu00@gmai
l.com
8. Mother Tongue :
(As per school/college record)
KANNADA 9. Annual Income of the
Family from all Sources :
11000
12. Reservation Category : Category-3B 13. Name of the Caste : LINGAYAT
15. Place where you wish to appear for CET-2015 ? BANGALORE (BENGALURU)
17 a. If CBSE / CISCE School Name
:
17 b. Are you appearing for Karnataka 2nd PUC Annual Examination 2015 ? No
17 c. If No enter the year of passing : 2014
Address : HEMANTH NC , NAGHENAHALLI, BELAGUMBA, ARSIKERE, HASSAN, KARNATAKA -
573103
STD Code : 91 Phone Number : 9535876015
4. Date Of Birth: 12-06-1996 5. Gender: Male
21. Are you claiming reservation under Article 371(J) Hyderabad Karnataka ? No
22.Candidate's Postal Address for Communication
Study Details
Details of Appearing Previous CET Exams
29. CET NO:
30. Mention the year of appearance:
Candidate Details
17. Qualifying Examination : Karnataka 2nd PU
14. Eligibility Clause Code : a
16. Examination Place Code : 3
17 d. If yes please enter PUC Student Number :
Study Information
18. Total Number of completed years of study in Karnataka : 12
19. Have you studied in Rural area in Karnataka from 1st to 10th standard ? No
20. Have you studied in Kannada Medium from 1st to 10th standard ? No
Qualifying Examination Details
23. Have you studied SSLC/10th standard in
Karnataka?
No
27. Special Category:
28. Are you claiming Agriculturist Quota Reservation? No
28 a. Agriculture Practical Exam Centre:
24. State where appeared for
2nd PUC/12th/Equivalent ?
KARNATAKA 24 a. 2nd PUC District
(If Karnataka):
BANGALORE URBAN
(BENGALURU URBAN)
25. Native State : KARNATAKA 25 a. Native District
(If Karnataka):
HASSAN
26. Are you a Son/Daughter of Jammu & Kashmiri Migrant ? No
04-06-2015 11-40-30Printed Date:
Final Copy

2. Left Hand Thumb
impression of the
Candidate
Signature of the
Candidate
Signature of the
Parent / Guardian
Date:
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 shall forfeit the claim to be considered or a seat selected and allotted by KEA. We are also liable for
civil and criminal action, that the State Government or the KEA may take against us in this regard.
Name:
Signature:
Seal:
Principal / Gazetted Officer Signature
Payment Status
Application Number: 100296 Name of the
Candidate:
HEMANTH N C
Application Fees: 650 Bank/Post Office
Name:
e-Post Office
Bank/PO Charges: 10 Bank/Post Office Ref
Number:
186182026
Total Amount: 660 Date of Payment: 25-02-2015
Declaration
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.
Complete Name & Address of theSchool / College
with Telephone Number
Classes
studied
Year of
study From
Year of
study To
Year of
Passing
Sharadha English School
BH-road,Arsikere
Hassan-573103
1 2002 2003 2003
Sharadha English School BH road,Arsikere Hassan 573103 2 2003 2004 2004
Sharadha English School BH road,Arsikere Hassan 573103 3 2004 2005 2005
Sharadha English School BH road,Arsikere Hassan 573103 4 2005 2006 2006
Sharadha English School BH road,Arsikere Hassan 573103 5 2006 2007 2007
Sharadha English School BH road,Arsikere Hassan 573103 6 2007 2008 2008
Sharadha English School BH road,Arsikere Hassan 573103 7 2008 2009 2009
Sri Basavarajendra High School BH road,Arsikere Hassan 573103 8 2009 2010 2010
Sri Basavarajendra High School BH road,Arsikere Hassan 573103 9 2010 2011 2011
Sri Basavarajendra High School BH road,Arsikere Hassan 573103 10 2011 2012 2012
VV Puram College of Science
KR Road Bangalore
11 2012 2013 2013
VV Puram College of Science
KR Road Bangalore
12 2013 2014 2015
04-06-2015 11-40-30Printed Date:
Final Copy