Print Date & Time : 7/14/2016 11:37:00AM

JAI NARAIN VYAS UNIVERSITY, JODHPUR

Candidate Registration Form
SESSION : 2016 - 2017

(010) DEPARTMENT OF CIVIL ENGINEERING

Registration No. : J16U505018

Degree : B.E.

Applying For : GRADUATION

Registration Date : 14/07/2016

Form No. : DCE00278

Qualifying Exam Roll/Form No. :5025680

1. Name of the Candidate (

Enrollment No. :NA

(IN BLOCK LETTERS) :

GAURAV VERMA
Name of the Candidate (

(IN HINDI) :

2. Father's Name (

(IN BLOCK LETTERS) :

MR. PREMRAJ VERMA

Father's Name (

(IN HINDI) :

3. Mother's Name (

(IN BLOCK LETTERS) :

MRS. KANTA VERMA

Mother's Name (

(IN HINDI) :

RAJASTHAN

4. Date of Birth :

07/06/1999

5. Domicile :

6. Gender :

MALE

7. Res. Category :

8. Category :

SC

9. Caste Name :

BAIRWA

10. Income Tax Payer :

NO

11. Aadhar No. :

603996928927

12. Nominee Name/Relation :

PREMRAJ VERMA

13. Is Working? :

NO

14. Company Name :

NA

HINDU

17. Email ID :

gouravverma247@gmail.com

19. Nationality :

INDIAN

15. Other Category :

16. Religion :

18. Do You Belong To Minority Category? :

NO

20. Have You Taken No Objection Certificate From (SP) (Optional) :

NO

21. Address

ENGLISH

22. Medium
Permanent Address

Address of Correspondence

Address :
PLOT NO.16 SHYAM NAGAR BEHIND
SHANI MANDIR

Address :
PLOT NO.16 SHYAM NAGAR BEHIND
SHANI MANDIR

District :

District :

Pin :

SAWAI MADHOPUR
322001

Pin :

Photo of Candidate

SAWAI MADHOPUR

Signature of Candidate

322001

Phone :
Mobile :

9660106076

Unique Identification Details

23. 10th Marksheet Sr. No. :

0434221

24. 10th Roll No. :

0821032

25. 10th Passing Year :

2013

26. 12th Roll No. :

1631027

Last Submit Date & Time ( 7/14/2016 11:36:41AM) IST

Last Updated Date & Time ( 7/14/2016 11:36:41AM ) IST

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Print Date & Time : 7/14/2016 11:37:00AM

27. Whether you were punished for any offense / unfair means committed by you in the previously attended or the
present institution (If yes, give details ) :
28. Weightages Claimed :

29. Academic Record :

S. No. Examination Passed

Year

Max
Marks

Percentage/ ExamStream
Grade

Obt.
Marks

Matriculation

2013

600.00 441.00

73.50%

Intermediate

2015

500.00 411.00

82.20%

Subjects

Board/University

Rajasthan Board of
Secondary Education,
Ajmer-305 001.
Physics Chemistry
Mathematics

Rajasthan Board of
Secondary Education,
Ajmer-305 001.

30. Subject Details :

Compulsory subjects
1

--NA--

List of subjects/Combination and their preferences.

S. No. Subject Preferences

Preference

Civil Engineering

NOTE: Mark the number of documents ( Photocopy/Xerox) attached by the Candidate during form submission to the college :
(a)

Xth Marksheet

(b) Xth Certificate.

(c) XIIth Marksheet.

(d)
(g)
(j)
(m)

Last Exam Passed Marksheet

Domicile (for other state)
Certificate for Vert./Caste Category
Migration Certificate

(e)
(h)
(k)
(n)

(f) Signature
(i) Certificate for Horz./Reservation Category
(l) Character Certificate
(o) Gap year Certificate

Photograph
Certificate for Kashmiri Migrants.
Transfer Certificate
Income Certificate

(p) Ward of University(if Applicable)

Undertaking
1. /
/ |
2. / |
3. / ,
/
/ |

4. / / |
5. / / 100%
/ 75% / |
6. , / / |
7.

|
/
/ | / |
/ / |

Dated :

Signature of the Applicant him / herself

Signature of Parent's/Guardian
Last Submit Date & Time ( 7/14/2016 11:36:41AM) IST

Last Updated Date & Time ( 7/14/2016 11:36:41AM ) IST

Student Receipt
Registration No. : J16U505018

Registration Date : 14/07/2016

Print Date & Time : 7/14/2016 11:37:00AM

Form No. : DCE00278

College Name : (010) DEPARTMENT OF CIVIL ENGINEERING

Degree :

Receiver's Signature

B.E.
Last Submit Date & Time ( 7/14/2016 11:36:41AM) IST

Last Updated Date & Time ( 7/14/2016 11:36:41AM ) IST

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