DIRECTORATE OF TECHNICAL EDUCATION, CHHATTISGARH, RAIPUR

APPLICATION FORM FOR ALLOTMENT/ADMISSION TO FIRST YEAR OF FOUR-YEAR FULL-TIME

DEGREE COURSES IN ENGINEERING / TECHNOLOGY FOR THE ACADEMIC YEAR 2014-2015

Based on CG PET-2014

APPLICATION ID : EN14113412 VERSION NO : 2 PET-2014 ROLL NO : 25081383

Personal Details :Candidate's Name JAYENDRA KUMAR

Father's Name SANJAY KUMAR Mother's Name BASANTI BAI

Domicile Status ChhattisgarhDomicile

Category OBC

Date Of Birth September 22, 1996 Gender Male

Mother Tounge Hindi Family Income ( ) <1,00,000

Religion Hindu Region Rural

Belong to BPL Class No

CorrespondenceAddress

S/o MR. SANJAYKUMAR VILLAGEPOST BARBANDA VIAMANDHAR COLONYRAIPUR

PermanentAddress

S/o MR. SANJAYKUMAR VILLAGEPOST BARBANDA VIAMANDHAR COLONYRAIPUR

State Chattisgarh State Chattisgarh

District Raipur District Raipur

Block Dharsiwa Block Dharsiwa

Pin Code 493111 Pin Code 493111

Telephone 1 () Telephone 2 ()

E-Mail ID Mobile No 9617348399, 9926297892

Special Reservation Details :Belong to Sainik Class No Belong to Freedom Fighter Class No

Belong to Person with Disability Class No

PET-2014 Details :Physics Marks 17.347 Chemistry Marks 11.000

Mathematics Marks 19.388 Total Marks 47.735

General Rank 9611 Category Rank 3994

12th Std./H.S.C. Details :Physics Marks 57.00 / 100.00 Chemistry Marks 73.00 / 100.00

Mathematics Marks 56.00 / 100.00 Aggregate Marks 283.00 / 500.00

Physics, Chemistry and Mathematics Marks 186.00 / 300.00

H.S.C. Board Chhatisgarh Board of Secondary Education (CGBSE), Raipur

H.S.C. Roll No. 2141803461 Year of Passing 2014

Name of School/Institute GOVT H S SCHOOL MANDHAR RAIPUR

Counseling Fees Details :

Challan Amount ( ) 300/- Challan Date July 7, 2014

Bank Name State Bank of India Branch Name BAIRAN BAZAR

City Name RAIPUR

List of copies of Documents required to submit at Document Verification Centre (Originalsmust be shown at Document Verification Centre for Verification) :

Sr. No. Docum ent Nam e

1. Rs. 300/- Challan for Counselling Fee.

2. S.S.C. (Std.X) Mark Sheet.

3. H.S.C. (Std.XII) / Diploma Mark Sheet.

4. PET-2014 Score Card.

5. Domicile Certiif icate issued by any Authorisied/Competent Off icer in Proforma - 5 / 6 / 7 / 8 as Applicable.

6. Permanent Caste Certif icate (Leaving Creamy Layer) in Proforma - 2.

7. Caste Verif ication Certif icate.

Declaration

I have read Information Brochure and all the rules of allotment and on understanding theseRules, I have filled this Application Form for consideration of submission of application form at DocumentVerification Centre(DVC) for the Allotment to Engineering / Technology Course for the academic Year 2014-2015. The information given by me in this application is true to the best of my knowledge & belief. If at laterstage, it is found that I have furnished wrong information and/or submitted false certificate(s), I am awarethat my allotment stands cancelled. Further I will be subject to legal and/or penal action as per the provisionsof the law.

Place : Date :

Printed On : July 7, 2014 12:20:52 PMApplication Last Modified On : July 7, 2014 12:20:39 PM

Signature of Candidate (JAYENDRA KUMAR)

DIRECTORATE OF TECHNICAL EDUCATION, CHHATTISGARH, RAIPUR

OPTION FORM FOR ALLOTMENT/ADMISSION TO FIRST YEAR OF FOUR-YEAR FULL-TIME

DEGREE COURSES IN ENGINEERING / TECHNOLOGY FOR THE ACADEMIC YEAR 2014-2015

Based on CG PET-2014

APPLICATION ID : EN14113412 VERSION NO : 2 PET-2014 ROLL NO : 25081383

Options Given By Candidate :

Preference

No

Institute

CodeInstitute Name

University

NameStatus

Choice

CodeCourse Name

1 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11405Electrical & Electronics

Engineering

2 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11410 Mechanical Engineering

3 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11407

Electronics & Tele

Communication

Engineering

4 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11404Computer Science &

Engineering

Declaration

I have read Information Brochure and all the rules of allotment and on understanding theseRules, I have filled this Option Form for consideration of submission of Option Form at Document VerificationCentre(DVC) for the allotment to Engineering / Technology for the academic Year 2014-2015. The information given by me in this Option Form is true to the best of my knowledge & belief.At later stage, if it is found that I have furnished wrong information then I am fully aware that the Option Formsubmitted will not be altered/modified/changed in any case and I will be responsible for any furtherconsequences arises due to my mistake. I also undertake that options filled by me are may own choice, I havefilled it based on my own inclination/knowledge and not due to any pressure/ignorance/unwanted influence. I also herewith undertake that, at later stage, if it is found that I have submitted falsecertificate(s)/document(s), I am aware that my allotment stands cancelled. Further I will be subjected to legaland/or penal action as per the provisions of the law.

Place : Date :

Option Form Printed On : July 7, 2014 12:20:52 PMOption Form Last Modified On : July 7, 2014 12:20:39 PM

Signature of Candidate (JAYENDRA KUMAR)