REGISTRATION FORM: 2017-18
Course
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Student Name :
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Personal E-Mail:
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Student Mobile No. 1
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Student Mobile No. 2
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Date of Brith
MM
/
DD
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YYYY
SEX
Name of Father/Guardian
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Father’s Email
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Mobile
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Permanent Address: Flat/Door/Block No
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Permanent Address: Name of Premises/Building/Village
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Permanent Address: Road/Street/Lane/Post Office
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Permanent Address: Area/Locality/Taluka/Sub-Division
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Permanent Address: Town/City
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Permanent Address: District
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Permanent Address: State
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Permanent Address: Pin Code
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Nationality
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Religion
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Category :
Exam Passed 10th
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Name of Subjects 10th
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Year of Passing 10th
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% of Marks 10th
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Examining Board/University 10th
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Exam Passed 12th
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Name of Subjects 12th
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Year of Passing 12th
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% of Marks 12th
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% Marks in PCM 12th
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Examining Board/University
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Exam Passed Graduation
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Name of Subjects in Graduation
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Year of Passing Graduation
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% of Marks in Graduation
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Examining Board/University
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Any other Examination
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UPSEE-2017
UPSEE-2017 Roll No
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Combined Merit Position
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Any other (Specify)
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Roll No.
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Merit Position
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Hostel Facility Required
Bus Facility Required
Reference
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