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Application | Under Graduate | MHT-CET 2019

Personal Details/व�य��क म���त�

NOTE - The Candidate name should be filled as available on your SSC or equivalent and or HSC or equivalent Examination Marksheet or Board Certificate.

Application No.: Candidate's First Name/उम�दव�र�च� प�हल� न�व:


110240818 DEEP

Father or Husband's Name/वड�ल �क�व� पत�च� न�व: Candidate's Last Name/उम�दव�र�च� आडन�व:
DILIP MANE

Candidate's Mother's Name/आईच� न�व: Gender/�ल�ग:


DIPTI M

Date of Birth/जन्मत�र�ख:
07/06/2001

Mobile No. of Candidate/भ्रमण ध्वन�: E- Mail ID of the Candidate/ई - म�ल आयड�:


9326541392 DEEPMANE10102@GMAIL.COM

Payment Status: Payment Mode: Exam Fee:


PAID ONLINE 800.00

Permanent Address/क�यम�� प��

Permanent Address/क�यमच� पत्त�: Permanent State/क�यमच� र�ज्य: Permanent District/क�यमच� �ज��:


ROOM NO 401 OM SAIDHAM APT 4TH FLOOR SAMBHAJI NAGAR BEHIND ROYAL CHALLENGE HOTEL MAHARASHTRA THANE
WAGLE ESTATE THANE WEST

Permanent Taluka/क�यमच� त�ल�क�: Permanent Village/क�यमच� ग�व: Permanent Pincode/क�यमच� �पनक�ड:


THANE THANE (M CORP.) 400604

Is your Correspondence Address same as Permanant Address?/आपल� पत्रव्यवह�र�च� पत्त� व क�यमच�


पत्त� सम�न आह� क�?:
YES

Address for Correspondence/पत्रव्यव��र��� प��

Correspondence Address/पत्रव्यवह�र�च� पत्त�: Correspondence State/पत्रव्यवह�र र�ज्य: Correspondence District/पत्रव्यवह�र �ज��:


ROOM NO 401 OM SAIDHAM APT 4TH FLOOR SAMBHAJI NAGAR BEHIND ROYAL CHALLENGE HOTEL MAHARASHTRA THANE
WAGLE ESTATE THANE WEST

Correspondence Taluka/पत्रव्यवह�र त�ल�क�: Correspondence Village/पत्रव्यवह�र ग�व: Correspondence Pincode/पत्रव्यवह�र �पनक�ड:


THANE THANE (M CORP.) 400604

Other Details/इतर म���त�

Are you an Indian National?/आपण ��रत�य आह�त क�?: Domicile Certificate of State/आप��कड� क�ण�� र�ज्य�च� अ�धव�स प्रम�णपत्र आह� ?: Category of Candidate/उम�दव�र�च� प्रवग�:
YES MAHARASHTRA OPEN

Do you possess Caste Certificate from Maharashtra?/आप��कड� मह�र��� �च� ज�त प्रम�णपत्र आह� क�?: Do you possess Caste Validity Certificate?/आप��कड� ज�त व�धत� प्रम�णपत्र आह� ?: Caste Validity Certificate No./ज�त व�धत� प्रम�णपत्र क्रम��क:
-- -- --

Caste Validity Receipt No./ज�त व�धत� अज� प�वत� क्रम��क: Do you possess Non Creamylayer Certificate (NCL)?/आप��कड� न�न-क्र�म� ल�यर च� प्रम�णपत्र आह� क�?: Non Creamylayer Certificate No./न�न क्र�म� ल�यर प्रम�णपत्र क्रम��क:
-- -- --

Non Creamylayer Receipt No./न�न क्र�म� ल�यर व�धत� अज� प�वत� क्रम��क: Non Creamylayer Certificate Valid Through Date/आपल� न�न-क्र��मल�यर प्रम�णपत्र क�ठ�� त�रख� पय�त व�ध Non Creamylayer Application Receipt Date/न�न-क्र�म�ल�यर अज� प�वत� त�र�ख:
-- आह� ?: --
-- Are you Person With Disability Candidate?/आपण �वकल��ग व्य�� आह�त क�?:
NO
Type of Disability/�वकल��गत�च� प्रक�र:

Do you Require Scribe/आप��ल� मदत�नस�च� आवश्यकत� आह� क�?: Do you Require ExtraTime/आप��ल� अ�धक व�ळ प��हज� आह� क�?:
-- --

J and K Migrant/ज�� क���र ��त�ल �थल��त�रत र�हव��� : Religion/धम�: Total Annual Family Income/उम�दव�र��� क�ट�� ��य��च� एक�ण व����क उत्पन्न:
NO HINDU 0 TO 2.5 LAKH

Have You Passed SSC / CBSE / ICSE / IB / IGCSE From India?/त��� दह�व�च� पर��� र�ज्य �� ट ��ड� / स���एसई / आयस�एसई /आय ��/आय ज� स� एस ई ��ड� मध�न ��रत�त�न उत�ण� ��ल� आह�त क�?:
YES

10th / SSC / CBSE / ICSE / IB / IGCSE Year of Passing/१० व�/ दह�व�च�/ स���एसई / आयस�एसई /आय 10th / SSC / CBSE / ICSE / IB / IGCSE Percentage Marks Obtained (Best of five)/१० व�/ दह�व�च�/ State where your 10th / SSC / CBSE / ICSE / IB / IGCSE School is situated/आपल� १० व�/
��/आय ज� स� एस ई च� उत्त�ण� व�� स���एसई / आयस�एसई /आय ��/आय ज� स� एस ई च� ट��व�र� (प�च सव�त्तम) दह�व�च� /स���एसई / आयस�एसई /आय ��/आय ज� स� एस ईच� ��ळ� क�ठ�� र�ज्य�त आह� ?
2016 86.40 MAHARASHTRA

District where your 10th / SSC / CBSE / ICSE / IB / IGCSE School is situated/आपल� १० व�/ Taluka where your 10th / SSC / CBSE / ICSE / IB / IGCSE School is situated/आपल� १० व�/ दह�व�च�/ 10th / SSC / CBSE / ICSE / IB / IGCSE School Name/आपल� १० व�/ दह�व�च�/ स���एसई / आयस�एसई /आय
दह�व�च� /स���एसई / आयस�एसई /आय ��/आय ज� स� एस ई च� ��ळ� क�ठ�� �ज���त आह� ? स���एसई / आयस�एसई /आय ��/आय ज� स� एस ई च� ��ळ� क�ठ�� त�ल���त आह� ? ��/आय ज� स� एस ईच� ��ळ� च� न�व
THANE THANE SHRIMATI SAVITRIDEVI THIRANI SCHOOL

Are you Appearing/Appeared 12th(HSC) Exam in 2019?/त��� २०१९ म�� ��र�व�च� पर��� द� त आह�त क�?: State where your 12th(HSC) College is situated/आपल� ��र�व�च� क�ल�ज क�ठ�� र�ज्य�त आह� ?: Year of Passing/उत्त�ण� व��:
NO MAHARASHTRA 2018

Mention the District/�ज���च� �नवड� कर�: Mention the Taluka/त�ल�क�च� �नवड� कर�: HSC School/College Name/��र�व��� ��ळ� च� / क�ल�जच� न�व:
THANE THANE RAMANANDA ARYA D A V COLLEGE

Physics & Chemistry/���तक��स्त्र आ�ण रस�यन��स्त्र: Mathematics/ग�णत: Biology/ज�व��स्त्र:


YES YES YES

Preference 1/प्रथम प्र�ध�न्य: Preference 2/द� सर� प्र�ध�न्य: Preference 3/�तसर� प्र�ध�न्य:
ENGINNEERING AND TECHNOLOGY PHARMACY DAIRY TECHNOLOGY

I want to have the Question Paper in/मल� म��� प्रश्नप�त्रक� �� ����त हव� आह� :
ENGLISH

First Preference District/प्रथम �ज�� प्र�ध�न्य: Second Preference District/द� सर� �ज�� प्र�ध�न्य:
THANE MUMBAI CITY

Candidate's Account Details - Your Account Number will be used by State CET Cell/उम�दव�र��� ब�क ������ म���त� - ��ईट� ��ल��र� त�म�� अक�उ� ट ��बर�� व�पर क�ल� ��ईल

Name of the Account Holder/��क ख�त�ध�रक�च� न�व: Name of the Bank/��क�च� न�व: Name of the Branch/��क��� ��ख�च� न�व :
DILIP TUKARAM MANE ABHYUDAYA COOPRATIVE BANK LOKMANYA NAGAR

Type of Account/��क ख���च� प्रक�र: Bank Account Number/��क ख���च� क्रम��क: Bank's IFSC Code/��क�च� आयएफएसस� क�ड:
SAVING 041011100002254 ABHY0065041

I Agreed
I have gone through the information brochure and understood the eligibility and qualifying criteria.
The details entered in the above application are filled in by me and verified by me and true to the best of my knowledge and are binding on me.
I understand I will be liable for penal action for submitting incorrect information.
I am submitting the form. I will not be able to edit the application form once I submit it.

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