NEET EXAM FORM-2019

(FILL THE FORM IN CAPITAL LETTER)

Candidate’s Name :
Mother's Name :
Father's Name :
Category :
Person with Disabilities:
Date of Birth :
Gender :
State of Eligibility(15% Quota):
Email Address:
Password:
Mobile No
Adhar Card No:
In case of Girl candidate, Are you only child of your parents?: YES / NO

Place Of Birth : State- p District-

Exam Center: (Angul/Balasore/Berhampur/Bhubaneswar/Cuttack/Rourkela/Sambalpur)

1) 2)

3) 4)

10th {Academic Details (CLASS – 10th or Equivalent)

School Board Name :

School Name:

School Address:

Year of Passing:

Percentage of Marks obtained in Class 10th :

11th {Academic Details (CLASS – 10th or Equivalent)

Name of the School / College:

Year of Passing:

State where Class XI School /College is located:

District where Class XI School/College is located:

 NEET EXAM FORM-2019
12th {Academic Details (CLASS – 12th or Equivalent}

12th Board Name:

College Name:

College Address:

District where Class XII School/College / Study Center is located :

Year of Passing:

Percentage of Marks obtained in Class 12th:

12th Roll Number :

Qualifying Examination Code:

Details of Marks of 12th Exams

Subjects Maximum Marks Marks Obtained

(English) :
(Physics) :
(Chemistry) :
(Biology */Bio-technology) :
Candidate Address:
House/ Door Number:

(Locality

Land Mark
Village / Town / City
Pin Code
State:
District:
Details of Parents/Guardian

Qualification Occupation Annual Income

Father's/Guardians

Mother's

Do you intend to wear Customary Dress contrary to the Dress Code while
appearing in NEET (UG) – 2019: YES / NO

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