zL ;MDGFY ;\:S'T I]lGJl;"8L4 J[ZFJ/

AFæ (External) V[GZM,D[g8 OMD" SD 5ZL1FF OMD"

lJnFYL"V[ TFH[TZGM 5F;5M8"
XF:+Lv5|YDJQF" (F.Y.B.A.) ;[D[:8Zv!
X{1Fl6S JQF" oZ_Z_vZ_Z! ;F.hGM OM8M VCL\ RM\8F0JMP
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sVF VZHLÒGL lJUTM lJnFYL"VMV[ 5MTFGF C:TF1FZYL SF/HLÒ5}J"S JF\RLG[ EZJLPf

lJnFYL"GL ;CL o
5ZL1FF S[gãGM SM0 G\AZo _______________________________________________________

5ZL1FF S[gãG]\ GFD o __________________________________________________________

slJnFYL"V[ GFDGL TDFD lJUT DFS"XL8 D]HA V\U|[Ò S[5L8, V1FZMDF\ EZJFGL ZC[X[Pf

lJnFYL"G\] 5]~\GFD o __________________________________________________________________

Surname Name Father/Husband Name

DFT'zLG]\ GFD o ____________________________________________________________________________

1. 5+jIJCFZG]\ ;ZGFD]\ (Correspond Address) o

1.1. ;ZGFD]\ (Address) o _________________________________________________________

1.2. TF,]SM (Taluko) o ___________________ 1.5. DMAF., G\AZ (Mob. No.) o _____________________

1.3. lH<,M (District) o ____________________ 1.6. 3ZGF G\AZ (Res. No.) o _______________________

1.4. 5LG SM0 (Pin Code) o _________________ 1.7. >vD[., V[0=[; (E-Mail) o __________________________

2. lJnFYL"GL V\UT DFlCTL (Personal Information) o

2.1.HgD TFZLB (Date of Birth) o ___________________2.9. WD" (Religion) : ____________________________

2.2.ZFlQ8=ITF (Nationality) o _____________________2.10. HFlT (Gender) : _________________(Male/Female)

2.3.ZC[9F6 lJ:TFZ (Resident Area) : __________________(Rural/Urban) 2.11. a,0 U|]5 (Blood Group) : _________

2.4.S[8[UZL (Category) : _________________________(General/OBC/SEBC/SC/ST/EWS/Other)

2.5.J{JFlCS DFlCTL (Marital Status) : __________________(Married/Unmarried)

2.6.lJS,F\U sCF S[ GF mf (P.H.) : ____________ s CF 4 TM T[ V\U[G]\ DFgI 5|DF65+ HM0JFG]\ ZC[X[Pf

2.7. lJnFYL"GM jIJ;FI (Occupation) : __________________________ s GMSZL SZTF lJnFYL"VMV[ N.O.C. GL GS, OZÒIFT
HM0JFGL ZC[X[Pf
2.8.S]\8]AGL JFlQF"S VFJS (Family Annual Income) : __________________

Shastri-SEM-1 2020-21 External Examination Form Page 1 of 4

 3. WMZ6v!Z S[ T[GL ;DS1F 5F; SZ[, 5ZL1FFGL lJUT (HSC or Equivalent Examinations Details) o

3.1.;L8 G\AZ (Seat No.) : ______________________________________________________________________

3.2.5ZL1FF S[gã (Exam Center) : __________________________________________________________________

3.3.DF;qJQF" (Month/Year) : ____________________________________________________________________

3.4.AM0"qVgI ;\:YFG]\ GFD (HSC Board) : ____________________________________________________________

3.5.D[/J[, U]6 (Obtain Marks) : _________________________ 3.7. S], U]6 (Total Marks) : _________________

3.6.8SF @ (Percentage) : _______________________________ 3.8. 5ZL6FD (Result Class) : ________________

4. VgI DFlCTL (Other Details) :

4.1.A[\SBFTF G\AZ (Bank A/c No.) : ______________________________________________________________

4.2.A[\SG]\ GFD (Bank Name) : __________________________________________________________________

4.3. A[\S A|FgR SM0 (Bank Branch Code) : __________________________________________________________

4.4. A[\S A|FgR XC[Z GFD (Bank Branch City Name) : __________________________________________________

4.5.VFWFZSF0" G\AZ (Adharcard No.) : ____________________________________________________________

5. XF:+L S1FF DF8[ 5;\N SZ[, 5F9IS|DGL lJUTo

5[5ZGM SM0
S|D 5[5Z 5;\N SZ[, lJQFIG]\ GFD VMOZ SZJFDF\ VFJTF lJQFIM
G\AZ

! ! C.F.1.1.1. VlGJFI" ;\:S'T (COM.SAN)

Z Z E.F.1.1.1. V\U|[Ò VG[ Sd%I]8Z (ENG/COM)

U]HZFTL (GUJ) / lCgNL (HIN) sSM.56 V[Sf

# # G.E.1.1.1.

VY"XF:+ (ECO) q ;DFHXF:+ (SOC) q .lTCF; (HISTORY) q 5|FrI

$ $ O.E.1.1.1. ZFHGLlT V[J\ VY"XF:+ (PRACHYA RAJNITI & ARTH) sSM.56 V[Sf

;FlCtI (SAH) / J[N (VED) / 5]ZF6[lTCF; (PUR) / GjIjIFSZ6 (N.

VYA.) / GjIgIFI (N.NYAY) / ZFDFG]HJ[NF\T (R. VEDANT) /
5 C.C.1.1.1
5 VG[ & Ol,THIMlTQF (F.JYO) / WD"XF:+ (DHA) / JF:T]XF:+ (VAS) / 5F{ZMlCtID
& C.C.1.1.2. (PAU) / ;J"NX"G (S.DARSHAN) / :JFDLP J[NF\T sV[;Pq H[Pf
(S.VEDANT S. (or) J.) sSM.56 V[Sf
;FlCtI (SAH) / J[N (VED) / 5]ZF6[lTCF; (PUR) / GjIjIFSZ6 (N.
VYA.) / GjIgIFI (N.NYAY) / ZFDFG]HJ[NF\T (R. VEDANT) /
Ol,THIMlTQF (F.JYO) / WD"XF:+ (DHA) / JF:T]XF:+ (VAS) / 5F{ZMlCtID
& * C.E.1.1.1
(PAU) / ;J"NX"G (S.DARSHAN) / :JFDLP J[NF\T sV[;Pq H[Pf
(S.VEDANT S. (or) J.) / lÊIFtDS ;\:S'T lX1F6 (KRIYATMAK S.S.)
sSM.56 V[Sf

GM\W o 5[5Z G\AZ 5 VG[ &DF\ H[ lJQFIqXF:+ 5;\N SZJFDF\ VFJ[ T[ H lJQFIqXF:+ 5[5Zv* DF\ 5;\N SZL XSFX[ GlCP

Shastri-SEM-1 2020-21 External Examination Form Page 2 of 4

 voo 5|J[XOMD" ;FY[ HM0JFGF YTF N:TFJ[H s0MSI]D[g8foov

 GLR[ NXF"J[, N:TFJ[Hs0MSI]D[g8fGL :Jv5|DFl6T GS, 5|J[X OMD" ;FY[ HM0JL OZÒIFT K[ HM VF5G[ ,FU] 50TF CMI T[
0MSI]D[g8 OMD" ;FY[ GCL HM0[, CMI TM VF5G]\ 5|J[X OMD" VF5MvVF5 ZN YI[, U6FX[4 H[GL SM.56 5|SFZGL HF6 VF5G[
SZJFDF\ VFJX[ GCLPH[GL BF; GM\W ,[JLP
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Zf Axis Easy Pay dFFZOT[ VMG,F.G OL EIF"GL ZL;L%8GL V[S GS,
#f XF/F KM0IFs:S], ,LlJ\UfGF 5|DF65+GL GS,
$f VeIF;DF\ HM ! JQF"YL JW] V\TZsU[5f CMI TM ~FPZ_GF :8[d5 p5Z ;M\UNGFD]\ VMZLhG, OMD" ;FY[ HM0J]\P
5f AFæ lJnFYL"V[ VM/BGF 5]ZFJF DF8[ R]\86LSF0" q VFWFZSF0" q 0=F.JL\U ,F.;g; q 5FGSF0" VYJF WMP!ZGL 5ZL1FF
ZL;L%8 DF\YL SM.56 V[SGL :Jv5|dFFl6T GS, HM0JL OZÒIFT K[P
&f ;ZSFZL GMSZL SZTF lJnFYL"VMV[ V[GPVMP;LP VMZLhG, HM0JFG]\ ZC[X[P

OL EIF"GL lJUT o s 5ZL1FF OL DF+ Axis Easy Pay DFZOT VMG,F.G H EZJFGL ZC[X[Pf
voo AFCI lJnFYL" DF8[oov

OL GL ZSD ~FP________________________qv s XaNMDF\ ZSD ~FP _____________________________________ f Axis Easy Pay Z[OZg;
G\AZ ____________________________ YL TFP ____________________ GF ZMH HDF SZFJ[, K[P H[GL V[S GS, VF ;FY[ ;FD[, K[P

v oo V[SZFZGFD] oov
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HFT[ BZF. SZL EZ[, K[ H[ ;\5}6" ;FRL K[P zL ;MDGFY ;\:S'T I]lGJl;"8LGF 5|JT"DFG VG[ ElJQIDF\ VD,L AGTF TDFD WFZFWMZ6M VG[
lX:TGF\ lGIDMG]\ C]\ R]:T56[ 5F,G SZJF AF\C[WZL VF5\] K\]P I]lGJl;"8L £FZF 5|l;wW YI[, AFæsV[18"G,fGF :JFwIFISFI" ;\,uG TDFD ;}RGFGM D[\
VeIF; SZ[, K[ TYF AFæ ;[D[:8Z 5wWlTGL VF ;FY[ ;FD[, TDFD ;]RGF TYF lGIDM D[\ SF/Ò 5}J"S JF\rIF K[ T[G\] 5F,G SZJF C]\ AF\C[WZL VF5]\
K]\P

Zf I]lGJl;"8L VG[ 5ZL1FF S[gãGF lGIDMG]\ R]:T56[ 5F,G SZLX4 T[D SZJFDF\ S;}ZJFZ 9~\ TM DFZF ;FD[ I]lGJl;"8L VG[ 5ZL1FF S[gãGF\ lX:TGF
lGIDMGL HMUJF. VgJI[ H[ 56 SFI"JFCL SZJFDF\ VFJX[ T[ DG[ A\WGSTF" ZC[X[P JW]DF\ RF,] X{1Fl6S JQF"oZ_Z_vZ! NZlDIFG C]\ H[ S1FFGL
5ZL1FF VF5JF DFU]\ K]\ T[ S1FFGL 5ZL1FF D[ VUFp SM. 56 I]lGJl;"8LDF\ VF5[, GYL T[DH zL ;MDGFY ;\:S'T I]lGJl;"8L S[ EFZTGL VgI SM.
I]lGJl;"8LDF\ SM. 56 VeIF; SZTMqSZTL GYLP

TFZLB o q qZ_Z_ PPPPPPPPPPPPPPPPPPPPPPPPPPP

slJnFYL"GL ;CLf

Shastri-SEM-1 2020-21 External Examination Form Page 3 of 4

s!f AFæGF lJnFYL"VMG[ 5ZL1FF S[gã=MGL 5;\NUL DF8[GL ;}lR o sSM. 56 V[S 5ZL1FF S[gã 5;\N SZXMfP

S|D 5ZL1FFS[gã sDCFlJnF,If G]\ GFD SM0 G\AZ

! zL V\lASF ;\:S'T DCFlJnF,I4 V\AFHL 0801
Z zL A|ïlQF" ;\:S'T DCFlJnF,I4 G0LIFN 0701
# zL lJP9FPRMS;L ;}I"5]Z ;\:S'T DCFlJnF,I4 ;]ZT 0504
$ zL JZT\T] ;\:S'T DCFlJnF,I4;M,F4 VDNFJFN 0110
5 zL ;MDGFY ;\:S'T I]lGJl;"8L ;\RF,LT ;\:S'T SM,[H4 J[ZFJ/ 1122
& zL AFA0[`JZ ;\:S'T DCFlJnF,I4 zL ;F\NL5GL lJnFlGS[TG4 5MZA\NZ4 2501

voo ;}RGFVM oov

*** AFæ lJnFYL"VMV[ T[DGF OMD" TFPZ_q_(qZ_Z_ ;]WLDF\ Z[uI],Z OL ;FY[ TYF TFP#_q_(qZ_Z_ ;]WLDF\ ,[.8 OL ;FY[ I]lGJl;"8LG[ D/[
T[ ZLT[ :5L05M:8 S[ ZÒPV[0LP VYJF S]ZLIZYL 5ZL1FF lGIFDSzL4 zL ;MDGFY ;\:S'T I]lGJl;"8L4 ZFH[gã E]JG ZM04
J[ZFJ/v#&Z Z&&4 ÒPULZv;MDGFY4 U]HZFTP GF ;ZGFD[ DMS,JFGF ZC[X[P

_!P VZHNFZ[ lGIT lJQFIM ;FY[ U]HZFT ZFHIGL CFIZ ;[Sg0ZL VYJF T[GL ;DS1F 5ZL1FF 5F; SZL CX[ TM T[DG]\ GFD GM\WL XSFX[P
_ZP VZHNFZ[ 5MTFGF 5|J[X5+ ;FY[ 5ZL1FF OL ~FP!___qv GL ZSD Axis Easy Pay dFFZOT[ VMG,F.G EZ[,L ZL;L%8GL V[S GS, TYF
T[D6[ 5F; SZ[,F CFIZ ;[Sg0ZL 5ZL1FFG]\ U]6 5+S4 5ZL1FFDF\ pTL"6 YIFG]\ 5|DF65+ TYF XF/F KM0IFGF 5|DF65+ sV[,P;Lf4
NZ[SGL V[S :Jv5|DFl6T GS, HM0JL VFJxIS K[P
_#P lGIT ;DIDIF"NFDF\ OMD" 5|F%T YX[ GCL VYJF H~ZL 0MSI]D[g8 HM0[,F CX[ GCL VYJF H~ZL OL ZL;L%8GL GS, HM0[, CX[ GCL T[JF
;\HMUMDF\ OMD" ZN U6FX[ T[DH T[ V\U[ SM. V,UYL HF6 SZJFDF\ VFJX[ GCL H[ AFAT[ GM\W ,[JLP
_$P H[ lJnFYL"VMGL H~ZL 8SFJFZL G D[/JJFG[ SFZ6[ I]lGJl;"8LDF\ 5|J[X DF8[ V5F+ 9IF" CMI q H~ZL lJQFI S[ lJQFIMDF\ pTL6" YIF G
CMI VYJF I]lGJl;"8LDF\ 5|J[X D[/JJF V\U[GF lGIDM ;FDFgITo ,FU] 50TF G CMI V[JF lJnFYL"GF 5|J[X OMD" ZN YX[P
_5P VF OMD"GL TDFD lJUT ;FRL TYF ;]JFrI V1FZMDF\ EZJLP V:5Q8 TYF R[SvRFS SZ[, OMD" ZN YJFG[ 5F+ U6FX[P
_&P XF:+LDF\ RF,] X{1Fl6S JQF[" V[GZM,D[g8 YGFZ lJnFYL"VMV[ D[vZ_Z5 ;]WLDF\ XF:+L VeIF;S|D 5}6" SZL ,[JFGM ZC[X[P HM D[vZ_Z5
;]WLDF\ XF:+LGM VeIF;S|D 5}6" SZX[ GCL TM T[DG[ lGIDFG];FZ 5]Go ZÒ:8=[XG SZJFG]\ ZC[X[P

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oo I]lGJl;"8LGF SFIF",I[ EZJFGL lJUTM oo

_!P ,3]¿D ,FISFT s3MZ6v!Z S[ T[GL ;DS1FfGL GS, YES / NO

_ZP lGIT OL EIF"GL ZL;L%8GL GS, YES / NO
_#P lGIT TFZLBDF\ OMD" 5|F%T YI[, K[ S[ GCLP YES / NO
_$P OMD"GL V\NZ DFlCTL IMuI K[ S[ GCLP YES / NO
_5P VgI H~ZL ,FU} 50TF 0MSI]D[g8 K[ S[ GCLP YES / NO
_&P VgI lZDFS"; HM CM. TM o YES / NO _____________________________

Checked By: Verified By :

sS,FS"4 5|J[X lJEFUf DFgI q VDFgI sVlWSFZLzL4 5|J[X lJEFUf
TFZLB o v vZ_

Shastri-SEM-1 2020-21 External Examination Form Page 4 of 4