Sr. No.
(As shown in display list)_________________
FORM FOR DOCUMENT VERIFICATION FOR MBBB/BDS COURSES, SESSION 2019
University Registration ID no.__________________ Dated________________
(To be filled by the Candidate in his / her own handwriting)
1. Category applied for
(please tick the category (B.A(14)/Br.A.(15)/PWD(16)/RA/TA(18-21)/Armed forces personnel-
(ies) claimed) (Defence)(22-30)/ P.P./Para Military ,etc.(31-33)/F.F(34)J&K(35)
2. NEET Roll No ___________________ 3. NEET Marks ______________
4. NEET Rank ___________________ 5. NEET Percentile ______________
6. Name of the Candidate __________________________________________________
7. Father's Name __________________________________________________
8. Date of Birth __________________________________________________
9. Age as on 31.12.2019 __________________________________________________
10. Name of School & State 10+1 ______________________________________________________
from where +1 & +2 10+2 ______________________________________________________
Passed
11. Aadhaar Card No. ______________________ Mobile No.__________________
12. Permanent Address
13. Email-ID (valid) __________________________________________________
14. Residence State __________________________________________________
15. Category Under Resident __________________________________________________
State as per PB.Govt. letter
no.1/3/95-3PP II/9619
dated 06.06.1996
16. Issuing authority for grant __________________________________________________
of Residence certificate
17. If applied to other state for
Yes No
admission to MBBS/BDS
Course
18. If yes, Name of the State
applied for admission
19. Whether applied under NRI/OCI/PIO in Yes No
centralized Counseling (Tick Yes/No)
20. Marks in 10+1 and 10+2:
Marks obtained/ Total Marks
Physics Chemistry Biology English
Total of PCB
Obt. Out of Obt. Out Obt. Out Obt. Out Obt. Out of %age
Class Passing Year of of of
10+1
10+2
UNDER TAKING / SELF DECLARATION BY THE CANDIDATE
Certified that I_________________________________________S/o Mr./Mrs______________________________
resident of ________________________________________ do hereby undertake that:-
1. That I am a citizen of India.
2. That I have not obtained the benefit of Residence for admission in MBBS/BDS courses in any other
State/UT except central counseling by MCC / DGSE.
3. a) That I have applied elsewhere in any other State/UT for admission to MBBS/BDS Courses, session 2019
in State Quota Counseling.
Or
b) That I have not applied elsewhere in any other State/UT for admission to MBBS/BDS Courses, session
2019 in State Quota Counseling.
4. That the above said information is true to the best of my knowledge and nothing is concealed therein. If at
any stage, the information provided is found false/wrong, the admission of my son/daughter/ward is liable to
be cancelled.
Thumb Impression
(Left in case of male/Right in case of female)
Signature of Candidate
(Following Documents to be checked by the document securitizing team)
Remarks by the Checker Signature
Checking Officer
1. NEET-UG-2019 Result Card
2. Matric - Certificate for checking date of
TH
Birth (10 )
3. 10+1 Detail Marks Card (DMC)
4. 10+2 Detail Marks Card (DMC)
5. Schooling Certificate of +1 & +2
(Last Attendant)
6. Residence Certificate as per PB.Govt. letter
no.1/3/95-3PP II/9619 dated 06.06.1996
7. Certificate of reserved
category (ies)
8. Exemption certificate for doing 10+1 & 10+2
from outside Punjab ( If applicable)
9. Bank Challan Form for submission of
Admission Application Fee
Discrepancy found (in any) .....................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Signature of document securitizing team in-charge
MEMBER MEMBER MEMBER MEMBER MEMBER
MEMBER MEMBER MEMBER CHAIRPERSON
