GOVERNMENT OF TAMIL NADU

DIRECTORATE OF MEDICAL EDUCATION

TAMIL NADU MBBS / BDS ADMISSIONS 2019 GQ
GOVERNMENT QUOTA

Application No. : 520376

Personal Information

Name NITHISHA G Nativity Tamil Nadu

Parent Name M GOVINDARAJ Religion HINDU
NITHISHA G NO.3,
RAJARATHINAM NAGAR,
CHENNAI SALAI
Permanent Address EXTENSION, OLD Community MBC/DNC
KATPADI, VELLORE PIN -
632007 VELLORE TAMIL
NADU -632007
Mobile Number 8344744378 Caste Name - Code Jangam.-11
Email malargovind1978@gmail.com Aadhar Number 722566668439
Date of Birth 25-11-2000 Nationality INDIAN
Gender FEMALE

Special Reservation Information

Eminent Sports Person NO Differently Abled Person NO

Exservicemen NO

School of Study Information

Studied VI,VII,VIII, IX, X, XI & XII Std. in Tamil Nadu School of

YES
Study

Class Year of Passing Name of the School District State

ST.MARK'S MATRIC.
VI Std. 2012 HR.SEC.SCHOOL,KATPADI, VELLORE TAMIL NADU
VELLORE
ST.MARK'S MATRIC.
VII Std. 2013 HR.SEC.SCHOOL,KATPADI, VELLORE TAMIL NADU
VELLORE
ST.MARK'S MATRIC.
VIII Std. 2014 HR.SEC.SCHOOL,KATPADI, VELLORE TAMIL NADU
VELLORE
ST.MARK'S MATRIC.
IX Std. 2015 HR.SEC.SCHOOL,KATPADI, VELLORE TAMIL NADU
VELLORE

ST.MARK'S MATRIC.
X Std. 2016 HR.SEC.SCHOOL,KATPADI, VELLORE TAMIL NADU
VELLORE
SUNBEAM
XI Std. 2017 MATRIC.HR.SEC.SCHOOL, VELLORE TAMIL NADU
KATPADI, VELLORE
SUNBEAM
XII Std. 2018 MATRIC.HR.SEC.SCHOOL, VELLORE TAMIL NADU
KATPADI, VELLORE
 NEET Information

NEET Roll Number NEET Reg No NEET Mark

411403769 190410168994 322

Academic Information

Qualifying Examination HSC

Name of the Board of Examination Tamilnadu-Tamilnadu Board of Higher Secondary Education
HSC/Equivalent Register Number & Year : 1684544 - 2018
HSC Group & Group Code : HSC Academic - 103
Undergoing / Completed any Professional courses. : NO
Passed all the subjects of HSC / Equalent examination in No. of
1 - Passed all the subject in First Attempt
attempts :
Marks Obtained in HSC (Academic/Equivalent) Examination
Subject Register Number Month Year Maximum Mark Obtained Mark
Physics 1684544 Mar 2018 200 192
Chemistry 1684544 Mar 2018 200 178
Biology 1684544 Mar 2018 200 169
Other 1684544 Mar 2018 200 198

Civic Information

Mother Tongue TAMIL Civic Native Corporation

Medium Of Instruction ENGLISH Civic School Corporation
Parent Occupation Private Organization Native District VELLORE
Annual Income Rs. 2,50,001 - 6,00,000
My Brother / Sister availed First
First Graduate Tuition Fee
NO Graduate Tuition Fee NO
Concession
Concession

I sincerely affirm that the information furnished above are true.

Place :
(Signature of Applicant)
Date :
 TAMIL NADU MEDICAL ADMISSIONS 2019
Application for Admission to MBBS / BDS Course

Application No. : 520376

A copy of the following Certificates has to be enclosed with the application form and the signed application
will be sent to Directorate of Medical Education, Selection Committee, #162, Periyar E.V.R. High Road,
Kilpauk, Chennai-600010

1. Transfer Certificate
2. 10th Mark Sheet
3. 11th Mark Sheet
4. 12th Mark Sheet
5. First Graduate Certificate (If applicable)
6. Certificate for proof of study from VI std to XII std.
7. Permanent Community Certificate Card (Permanent card / electronic form / digitally signed e-Certificate)
8. NEET UG 2019 Score Card
9. Special Reservation Form For Eminent Sports Person and relevant certificates (if applicable)
10. Special Reservation Form For Children of Ex-servicemen and relevant certificates (if applicable)
11. Special Reservation Form For Persons with Benchmark Disabilities and relevant certificates (if applicable)
12. Income certificate (Only for SC / SCA / ST candidates)
13. Nativity certificate for the candidates who have partly or completely studied outside Tamil Nadu from standard VI
to standard XII
14. Parents Certificate
1. Birth Certificate or Ration Card or Passport.
2. Study Certificate (10th or 12th or Degree Certificate)
3. Parent's Community Certificate

Printout of the application, Signed declaration and photocopies of all the above mentioned certificates need to be send to the
Directorate of Medical Education, Selection Committee, #162, Periyar E.V.R. High Road, Kilpauk, Chennai-600010.
 TAMIL NADU MEDICAL ADMISSIONS 2019
Application for Admission to MBBS / BDS Course

Application No. : 520376

Recent
Passport
size
Photo

DECLARATION BY THE APPLICANT

I,NITHISHA G( Son / Daughter / Ward) of M GOVINDARAJan applicant for MBBS / BDS 2019-2020session hereby solemnly declare
that I have not claimed Dual Nativity in this regard and I belong toMBC/DNC. (Community) and sub-caste Jangam.-11. I also declare that the
information and the statements given in the application and enclosures are true, correct & complete. I further declare that if it is found otherwise, I
will be liable to forfeit the seat and / or be removed from the rolls of the Institution at whatever stage of study. I may be, besides making me liable
for legal proceedings / Criminal action.

Place :
(Signature of Applicant)
Date :

DECLARATION BY THE PARENT / GUARDIAN

I,M GOVINDARAJ(Parent / Guardian) of NITHISHA G an applicant for MBBS / BDS course 2019-2020 session hereby solemnly
declare that I am fully aware of the above declaration & the particulars furnished are correct. I declare that if it is found otherwise, my ward will
be liable to forfeit the seat and also be liable for legal proceedings / Criminal action.s

Place :
(Signature of Parent / Guardian)
Date :

Note: Guardian can execute the above declaration,only if both the parents are not alive.
 GQ
REGD. POST / SPEED POST/COURIER SERVICE /BY PERSON
APPLICATION FORM FOR ADMISSION TO MBBS / BDS COURSE IN
GOVT. COLLEGES, IRT, RM, ESIC & GOVT. QUOTA SEATS IN
SELF-FINANCING MEDICAL / DENTAL COLLEGES IN TAMIL NADU
2019-2020 SESSION

APPLICATION NUMBER: 520376

NEET UG 2019 ROLL NUMBER: 411403769

NEET UG 2019 REG. NUMBER: 190410168994

NAME : NITHISHA G
QUALIFYING EXAMINATION : HSC
COMMUNITY : MBC/DNC
SPECIAL CATEGORY : NO

From : (Candidate’s Mailing Address)

To
-------------------------------------------------------------------------------------
The Secretary
-------------------------------------------------------------------------------------
Selection Committee,
-------------------------------------------------------------------------------------
No. 162, Periyar E.V.R. High Road
-------------------------------------------------------------------------------------
Kilpauk, Chennai – 600 010.

Note: Candidates seeking admission under Special Categories have to submit the Special Category Form along
with the General Category Application in the same cover. Otherwise they will not be considered under Special
Category. But candidates applying for Sports Category should produce Sports evidence certificate in person
only at the Selection committee.