Karnataka Minority Development Corporation Ltd.

,
(A Government of Karnataka Undertaking)
Address: S.R.Residency, Plot no.1881, 1st Floor, Opp L.S.Rathi Hospital, Old Jewargi
Road, Kalaburagi-585103 Phone: 08472-232425

Application For Loan Under Arivu CET Scheme

Board Of Study : StateBoard
Basic Details
Registration ID : 17KLB0161
SSLC Number : 20150495908

CET Number : PL209

NEET Number : 80867862 Date Of Birth : 07/03/1999

Student Name : NAHEED ANJUM

Name of Father/Husband/Guardian : ABDUL RAZAK

Place Of Birth : District : Kalaburgi
Taluk : Gulbarga Village : KALABURAGI

Mobile No : 9900388329
Gender : Female
Email ID : aejazap585@gmail.com Religion : Muslim
Annual Income : 20000 Martial Status : Unmarried

Permanent Address

Address : PLOT NO 117 AHMED NAGAR COLONY NEAR ALAND CHECK

POST KALABURAGI 585101
District : Kalaburgi Assembly Constituency : Kalburgi
Taluk : Gulbarga Town/Village : KALABURAGI
Pincode : 585101

Present Address

Address : PLOT NO 117 AHMED NAGAR COLONY NEAR ALAND CHECK

POST KALABURAGI 585101
District : Kalaburgi Assembly Constituency : Kalburgi
Taluk : Gulbarga Town/Village : KALABURAGI
Pincode : 585101

Occupation of the parent

Occupation of Father : Self Employed

Occupation of Mother : House Wife

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 Karnataka Minority Development Corporation Ltd.,
(A Government of Karnataka Undertaking)
Address: S.R.Residency, Plot no.1881, 1st Floor, Opp L.S.Rathi Hospital, Old Jewargi
Road, Kalaburagi-585103 Phone: 08472-232425

Occupation of Guardian :

Documents To Be Submitted To KMDC Kalaburgi District Office along with a

Printout of this Application that has a QR Code

->4 Passport Size Photograph of Candidate/Applicant

->Income and Caste Certificate
->Ration Card/Aadhar Card/Telephone bill/Water bill/KEB bill
->CET/NEET Admission Ticket
->SSLC Marks card
->Study Certificate (present course Non CET)
->Indemnity Bond
->College Fee Structure (Non CET)
->Previous Year Passed Marks Card (Non CET)

DECLARATION

I S/o, D/o, W/o .. declare that the above

information furnished by me is correct to the best of my knowledge and belief. I Further declare that
I will repay the loan amount along with service charges on schedule. I request you to send the loan
amount to the college in which I am presently studying for which I have requested loan.

Date:

Place:
Signature of Loanee/Student

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 DECLARATION BY THE PARENT/GUARDIAN

We solemnly declare that

1. My family income does not exceed Rs.6 lakh per annum from all sources.
2. I undertake to repay 10% of loan amount that is disbursed by the Corporation and additional
service charges through KEA towards Arivu Loan for the Education of my ward before seeking
further releases.
3. The loan amount availed by my ward along with the service charges will be repaid by me or my
Ward as per schedule.

Signature of Parent/Guardian

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