KARNATAKA RELIGIOUS & LINGUISTIC MINORITY PROFESSIONAL COLLEGES ASSOCIATION (Regd.) (K.R.L.M.P.C.

A)
Flat No.143, 4th Floor, 'SURYAMUKHI', Garden Apartments, # 21, Vittal Mallya Road, Bangalore 560 001. Ph.: 080 4112 1233 Fax: 080-4112 1266 Email : ________________ info@kmca.info ; admissions@kmca.info; : www.kmca.info ________________ ________________ website

APPLICATION FOR UNDER GRADUATE COMMON ENTRANCE TEST - 2013-14 (MEDICAL / DENTAL / ENGINEERING)
(Incomplete application is liable for rejection)
FILLED APPLICATION SHOULD BE SENT ADDRESSED TO THE CHIEF EXAMINER. DETAILED ADDRESS AS INDICATED ON THE TOP OF THE APPLICATION FORM 1. PERSONAL DETAILS a. The Course applied for : MEDICAL DENTAL ENGINEERING mark)

Paste your recent Passport size Photograph

b. Center you wish to appear for UG CET 2013 (Please choose any ONE center by putting BANGALORE RAICHUR GULBARGA MANGALORE

c. Name of the Applicant (IN BLOCK LETTERS)

d. Date of Birth: Date Month Year

e. ADDRESS FOR CORRESPONDENCE : (IN BLOCK LETTERS)

City: f. Telephone No. with STD Code no. : h. Email ID : i. Nationality : k. i) Do you belong to any of the following & Residing in KARNATAKA 1. Religion : Jain Muslim Sikh

State: g. Cell No. :

j. Gender :

Male

Female

2. Resident of Karnataka

ii) Do you belong to any of the following 1. Linguistics : Kodava Sindhi Tamil Telugu Tulu Konkani 2. Resident of Karnataka

iii) if you do not belong to any of the above please specify as GENERAL :

Please specify your home State : m. i) Father / Guardian' s Name : ii) Occupation : n. i). Mother's Name : ii) Occupation : iii) Annual Income : PA PA - Per Annum iii) Annual Income : PA

2. ACADEMIC DETAILS a. X Std / SSLC / SSC or equivalent : Name of the School State Year of Passing

a. XII Std / PU / 10 + 2 or equivalent : Name of the College State Year of Passing

c. Marks obtained in PU or Equivalent: SUBJECTS PHYSICS CHEMISTRY MATHS BIOLOGY ENGLISH AVERAGE OF PCB AVERAGE OF PCM 3. Enclose the following photocopies of certificate (ATTESTATION NOT REQUIRED): a. II Puc Marks Card ( if results are not declared please indicate RESULTS ARE AWAITED) b. Proof of Date of Birth c. DD for Rs.1000.00 drawn in favour of KRLMPCA payable at Bangalore d. One additional photograph needs to be sent with the above documents MAX. MARKS MARKS OBTAINED PERCENTAGE

I solemnly and sincerely affirm that the above information furnished by me is true and correct.

LEGAL JURISDICTION : BANGALORE KARNATAKA

(Signature of the Father / Guardian) Date

(Signature of the Candidate)

D D M M Y