Please provide the following Contact and Course Information:

* Indicates Mandatory Field *Name of the Candidate (in block letters only & as in S.S.L.C. marks card): *Address of the Candidate: *Place/City: *Data of Birth: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 *Nationality: *Religion / Caste: *Name of Parent / Guardian: *Educational Qualification: Father: Mother: *Occupation, Income of Parent / Guardian: Occupation: Income: *Year of Passing SSLC or equivalent Examination with Reg. No.: Year: Reg. No.: *Last school attended: *Date of leaving: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 *Whether eligibility certificate enclosed: (Note: Applicable to Non-Karnataka and candidates taken equivalent exam) Yes No *Number of full years the candidate actually studied in Karnataka: *Course applied for: Computer Science & Engineering Electronics & Communication Engineering Commercial Practice Apparel Design & Fashion Technology Mechatronics Civil Engineering *E-mail ID: