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14. DIFFERENT TYPES OF FORMATS / SPECIMEN OF PRESCRIBED FORMATS
(This Study Certificate PROFORMA is common to all the candidates)

PROFORMA FOR STUDY CERTIFICATE PROFORMA OF THE CERTIFICATE
TO BE PRODUCED BY NCC & SPORTS SPECIAL CATEGORY CANDIDATES
NAME, FULL POSTAL ADDRESS & TELEPHONE NUMBER OF THE (To be obtained from the Schools / Colleges)
INSTITUTION. NAME, FULL POSTAL ADDRESS & TELEPHONE NUMBER OF THE
Date ….…............... INSTITUTION.
This is to certify that Sri. / Kum. ........................ Date ….…...............
.......………. S/o / D/o ..........................……..............……..
has studied from ..............…......... standard to This is to certify that Sri. / Kum. ...............................……………. S/o
.……............. standard in our institution from / D/o ..................................……............... has participated in
…………………...... to ………..……........ academic
years. The mother tongue of the candidate is ..............…......…………….. NCC Camps / Sports events,
……………………………… as per the Admission register of the when he / she was a student of this institution
institution. The above details are true and correct to the best during ……………………. Standard. This is as per the NCC
of my knowledge. / Sports records maintained by this institution.
Signature of The above details are true and correct to the best of my
Institution seal Head of the institution knowledge.

(Name in Block letters..........................................) Signature of Head of the institution
Mobile number: (Name in Block letters..........................................)

Mobile Number:
COUNTER SIGNED BY ME
Address, Seal & Office Telephone Number Institution seal
of the Block Educational Officer / DDPI.
Mobile number:

AFFIDAVIT TO BE PRODUCED BY THE FATHER /
PÀ£ÀßqÀ ªÀiÁzsÀåªÀÄzÀ°è ªÁå¸ÀAUÀ ªÀiÁrzÀ §UÉÎ zsÀÈrÃPÀgÀt ¥ÀvÀæ
MOTHER OF THE HORANADU & GADINADU
KANNADIGA CANDIDATES ONLY
²æà ………………. gÀªÀgÀ ªÀÄUÀ / ªÀÄU¼ÀÄ …………. EªÀgÀÄ ………………………f¯ÉèAiÀÄ (TO BE TYPED ON RS. 20/- STAMP PAPER)
…………. vÁ®ÆèQ£À …………. UÁæªÀÄzÀ°è ªÁ¸ÀªÁVgÀĪÀ EªÀgÀÄ ………… vÀgÀUÀw¬ÄAzÀ
I, Sri. ….…………..………………………………… ……. .……… …
…...…. vÀgÀUÀwAiÀĪÀgÉUÉ ………..…... ±ÉÊPÀëtÂPÀ ªÀµÀð¢AzÀ ……………. ±ÉÊPÀëtÂP
S/o ………….…………..…………… Aged ……….… years
ªÀóµÀðzÀªÀgÉUÉÀ …...…………… ±Á¯ÉAiÀÄ°è PÀ£ÀßqÀ ªÀiÁzsÀåªÀÄzÀ°è ªÁå¸ÀAUÀ
residing at ………………………………... ………………do hereby
ªÀiÁrgÀÄvÁÛgÉAzÀÄ zsÀÈrÃPÀj¸À¯ÁVzÉ.
solemnly affirm and state on oath as follows:
zÁR¯Áw ¸ÀASÉå: : …………………………………………..
zÁR¯Áw ¢£ÁAPÀ :……………………………………….. I was a resident of …………………… (place) located at
……………………… District in Karnataka State. Presently
±Á¯É ©lÖ ¢£ÁAPÀ :………………………………………… I am residing at …………………………..… (place) located in
¸ÀÞ¼À : …………..……………… State. My son / daughter Mr. / Kum.
……...……………………….….………….... with CET Number
¢£ÁAPÀ : ……………… has appeared for the Common Entrance Test –
2018. My Mother tongue is ……………………….………….
(Kannada / Tulu / Kodava.) and my son / daughter is able to
read, write and speak Kannada language. In the proof of
±Á¯ÉAiÀÄ ªÀÄÄSÉÆåÃ¥ÁzsÁåAiÀÄgÀ ¸À» ªÉÄîÄgÀÄdÄ Kannada / Tulu / Kodava as the Mother Tongue of myself and
my son / daughter, I have sworn to this affidavit and submitted to
±Á¯ÉAiÀÄ ¥ÀÆtð «¼Á¸À, PÉëÃvÀæ ²PÀët C¢üPÁjUÀ¼À ¸À»,
the KEA for selection of seat under the Horanadu / Gadinadu
ªÉƺÀgÀÄ ªÀÄvÀÄÛ zÀÆgÀªÁt ¸ÀASÉå PbÉÃjAiÀÄ «¼Á¸À, ªÉƺÀgÀÄ Kannadiga candidate category.
I declare that the above information is correct to the best of my
ªÀÄvÀÄÛ knowledge and belief. In case any of the above information is
found to be false or incorrect, my son / daughter shall forfeit the
ªÉƨÉÊ¯ï £ÀA§gï: zÀÆgÀªÁt ¸ÀASÉå
seat allotted by the KEA. I hold myself also, liable for civil or
ªÉƨÉÊ¯ï £ÀA§gï: criminal action and the Government or KEA, Karnataka may take
appropriate action against me in this behalf.
Date: Deponent
Signature of the Candidate
Sworn before me

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