GOVERNMENT OF KARNATAKA


BACKWARD CLASSES WELFARE DEPARTMENT
APPLICATION
(Pre-Examination Training for the year 2018-19)


  # Indicates Optional
Fill up in Capital Letters
Amount in Rupees without Paise
1. Whether Physically Challenged?
2. Initial SSLC Details
SSLC Pass type SSLC Registration Number
SSLC Pass Year Date of Birth (DD-MM-YYYY)   
Religion
Category Category Caste
Belong to Central OBC ? OBC Caste
Applicant Name Father Name
Mother Name Gender
Caste Certificate No. Caste Name  Income Certificate No. Income in Rs. 
Applicant Details from Nadakacheri
Applicant Name Father Name
Applicant is eligible to apply for
Preference for Entrance Exam
3. Address
District Taluk
Village / Ward House No. / Door No.
Street / Road Area
PIN Code
4. Contact and Other Details
Applicant Mobile No. Alternate Mobile No.  #
Landline No. # eMail ID
Qualification Additional Educational Qualifications
(if any) like MBA / PhD etc. #
Father Profession Mother Profession
Aadhar No.
5. Bank Details
IFSCode Account No.
Bank Name Bank Branch
Branch Code MICR Code
6. Course Details
Belongs to Semester / Non Semester ?
Marks / CGPA ?
  Max Marks Obtained Marks CGPA Marks Memo
Semester - 1
Semester - 2
Semester - 3
Semester - 4
Semester - 5
Semester - 6
Semester - 7
Semester - 8
Total
   
7. Exam Centre Preferred by the Candidate for Common Entrance Test
8. Applicant Photo
9. Applicant Signature
10. Caste Certificate
11. Income Certificate
12. Copy of Aadhar
13. Copy of Bank Pass Book
14. SSLC Marks Card
15. Graduation Marks Memo
I hereby declare that the Information given above is correct to the best of my Knowledge. I am liable for criminal Proceeding against me, if the above is found to be incorrect.
I Accept Yes   No