Particular to be Filled by the Applicant
A. UET/PET Roll No. ............................
(for First Year students of a course)
1. Name of the Applicant ...................................................................................................................................
2. Sex (Male/Female) .........................................................................................................................................
3. Date of Birth ...................................................................................................................................................
4. Whether belongs to SC/ST/OBC/OBC Minority: Yes/No. ............................, If yes, Category ......................
5. Blood Group (If known) ................................................................................................................................
6. Identification marks .......................................................................................................................................
7. Any specific medical problem(s) ...................................................................................................................
8. Father's Name .......................................................................................................................................... ......
9. Mother's Name ................................................................................................................................................
10. Husband's Name (in case of married women) ...............................................................................................
11. Guardian's Name (if other than Father) ........................................................................................................
12. Relation of candidate with guardian ............................................................................................................
13. Permanent Address (Mention State, District, Town, Village & Post clearly)
.......................................................................................................................................................................
14. Police Station ..............................................................................................................................................
15. Name of the nearest Railway Station ............................................................................................................
16. Local Address (in the case city delegacy students) .......................................................................................
.......................................................................................................................................................................
17. 17. Whether ever Convicted/ Rusticated/ Debarred / Expelled Suspended ?
If "Yes" give details.
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
18. Name, Address and Telephone Nos. (if any) of person to be contacted in emergency.
(a) Outside Varanasi : .................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Phone: ....................................................... Mobile .....................................................................
Email id: ………………………………………………………
(b) Inside Varanasi : ..................................................................................................................................... ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Phone: ....................................................... Mobile .....................................................................
Email id:
Date: Signature of the Applicant