7/25/2017 DTE Naya Raipur Chhattisgarh

DIRECTORATE OF TECHNICAL EDUCATION, CHHATTISGARH, RAIPUR

APPLICATIO N FO RM FO R ALLO TMENT / ADMISSIO N TO

B.E. / B. PHARMACY CO URSES UNDER LATERAL ENTRY FO R THE ACADEMIC YEAR 2017-2018

APPLICATION ID : LE17434978 VERS ION NO : 1 ROLL NO : 2743713048

Personal Details :
Candidate's Name CHANDRESH KUMAR RATHORE
Father's / Husband's Name MILLU RAM Mother's Name SARASWATI BAI
Domicile Status Chattishgarh Category OBC
Domicile State Chhattisgarh
Date of Birth 15/11/1994 Gender Male
Mother Tounge Hindi Family Income Less than 50,000
Religion Hinduism Region Rural
Belong To BPL Class Yes - Card No. : 41020504330639 AADHAR No. 973331786763
Contact Details.
Correspondence Address 284, TELIKOT KHARSIA Permanent Address 284, TELIKOT KHARSIA
State Chhattisgarh State Chhattisgarh
District RAIGARH District RAIGARH
PinCode 496661 PinCode 496661
Telephone - Mobile No 7828990795
Email-Id rathore.chandresh123@gmail.com Gurdian Mobile No 8103568385
Special Reservation Details :
Belong to Sainik Class No Belong to Freedom Fighter Class No
Belong to Person with Disability Class No
Q ualification De tails - Diploma :
Qualification Mechanical Engineering Qualification Mode Regular
Passing Year 2016 University Name csvtu bhilai
College Name / Institute mansa polytechnic college bhilai
Overall Marks 3581.000 / 5000 (71.620%) Roll No 2743713048
5th Semester T heory Marks 308.000 / 500 (61.600%) 5th Semester Aggregate Marks 759.000 / 1000 (75.900%)
6th Semester T heory Marks 270.000 / 500 (54.000%) 6th Semester Aggregate Marks 751.000 / 1000 (75.100%)
Counselling Fees Details :
Fee Amount Online Payment Rs. 300 Deposit Date 25/07/2017 20:26:03
Fee Order Reference No 434978_2060586 Fee Paid Reference No IK00GHOOO2
List of copie s of docume nts re quire d to submit at Docume nt Ve rification Ce ntre (DVC)
(O riginal docume nts and photo copy of original docume nts along with printe d application cum option form must be shown at
Docume nt Ve rification Ce nte r for ve rification)
Sr.No. Document Name Sr.No. Document Name
1 10th Class Certificate or Birth Certificate * 2 Diploma Marksheet *
3 Domicile Certificate (Only in Proforma No. 5/6/7/8) ()* 4 Caste Certificate (OBC) *
5 BPL Card 6 AADHAR Card (Desirable)
Declaration
I have read Admission Rules for Technical Institute's of Chhattisgarh-2017 and on understanding these rules, I have filled the application form for
consideration of submission of application form at Document Verification Centre(DVC) for the allotment / admission to B.E. / B. PHARMACY COURSES
UNDER LATERAL ENTRY course for the academic year 2017-2018. The information given by me in this application is true to the best of my knowledge &
belief. If at later stage, it is found that I have furnished wrong information and/or submitted false certificate(s), I am aware that my allotment / admission shall be
cancelled and I shall be subjected to legal and/or penal action as per the provisions of the law.

Place : Date :
Printed On : Jul 25 2017 8:27:28:013PM Signature of Candidate
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7/25/2017 DTE Naya Raipur Chhattisgarh
Application Last Modified On : Jul 25 2017 8:26:36:543PM (CHANDRESH KUMAR RATHORE)

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7/25/2017 DTE Naya Raipur Chhattisgarh

DIRECTORATE OF TECHNICAL EDUCATION

CHHATTISGARH, RAIPUR
APPLICATIO N FO RM FO R ALLO TMENT / ADMISSIO N TO
B.E. / B. PHARMACY CO URSES UNDER LATERAL ENTRY FO R THE ACADEMIC YEAR 2017-2018

APPLICATION ID : LE17434978 VERS ION NO : 1 ROLL NO : 2743713048

Options Given By Candidate :

Pre fe re nce Institute Unive rsity Choice

Institute Name Status Course Name
No Code Name Code
Chhattisgarh Engineering College, Borsi-Dhanora
1 142 CSVT U PRIVAT E 14210 Mechanical Engineering
Road, Durg
Declaration

I have read Admission Rules for T echnical Institute's of Chhattisgarh-2017 and on understanding these rules, I have filled this option
form for consideration of submission of option form at Document Verification Center (DVC) for the allotment to B.E. / B. PHARMACY
COURSES UNDER LAT ERAL ENT RY for the academic year 2017-2018.

T he 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 form submitted will not be altered / modified / changed in any case I will
be responsible for any further consequences arises due to my mistake. I also undertake that options filled by me are my choice, I have filled 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 false certificate(s)/document(s), I am aware that my
allotment stands canceled. Further I will be subjected to legal and/or penal action as per the provisions of the law.

Place : Date :
Application Form
Jul 25 2017 8:27:28:013PM Signature of Candidate
Printe d O n :
Application Form Last
Jul 25 2017 8:26:36:543PM (CHANDRESH KUMAR RATHO RE)
Modifie d O n :

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