APPLICATION ID : RM3773 VALID PRINT

OFFICE OF THE CHAIRMAN,

NEET UG Medical & Dental Admission/Counseling Board-2022 AND
RUHS College of Dental Sciences (Govt. Dental College), Jaipur
NEET UG (MEDICAL / DENTAL) COUNSELING 2022 (MBBS, BDS) (State of Rajasthan)
APPLICATION FORM
Course applied for : MBBS Category : GENERAL
Opted for NRI seats : NO
Application ID : RM3773 NEET 2022 roll no. : 3903170383 Affix photo (as was
NEET 2022 score : 541 uploaded at the time
of filling on-line
Payment Type : APP. Reciept No. : 111675698997 Amount Rs. : 2000 application form)
Payment Type : CHOICE Reciept No. : 111686306850 Amount Rs. : 10000

Name : ARYAN AGRAWAL

Date of birth : 28-04-2003
Gender : MALE
Father's Name : ASHOK KUMAR AGRAWAL
Mother's Name : MADHU AGRAWAL
Present address : C/O ASHOK KUMAR AGARWAL FLAT NO G 1 PLOT NO Q127 NARAYAN VIHAR
SRINGARPURA JAIPUR RAJASTHAN, JAIPUR - 302020, JAIPUR, RAJASTHAN
Permanent address : C/O ASHOK KUMAR AGARWAL FLAT NO G 1 PLOT NO Q127 NARAYAN VIHAR
SRINGARPURA JAIPUR RAJASTHAN, JAIPUR - 302020, JAIPUT, RAJASTHAN
Residence phone : - Cell no. : 8561032581
email ID : aryan.garg1121@gmail.com
Birth State : RAJASTHAN
Domicile State : RAJASTHAN
Nationality : INDIAN
Category : GENERAL
PwD : NO
WDP / WPP : NOT APPLICABLE
EWS : NO
Family annual income is less than INR 2.5 lacs : NO
Aadhaar/Enrollment No. : 6332****2351
OTHER ELIGIBILITY CRITERIA

I. Natural father/Mother of the candidate has continuously resided in Rajasthan for period of last 10 years and the
candidate has studied for at least 5 years during this period in a recognized educational institution in Rajasthan

Educational details
Secondary (10th ) or an equivalent examination
Name of board : RAJASTHAN BOARD OF SECONDARY EDUCATION
Year of passing : 2017 Percentage of total marks : 75.00%
10 + 2 or an equivalent examination
Name of board : RAJASTHAN BOARD OF SECONDARY EDUCATION
Result status : PASSED Year of passing : 2019 No. of attempts : 1
Percentage of marks in Physics : 80.00%, Chemistry : 93.00%, Biology : 91.00%, English : 89.00%
Total percentage of Physics, Chemistry, Biology : 88.00 %

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APPLICATION ID : RM3773

Declaration :
I do hereby declare that all the information given by me in support of my application for registration is true, complete and
correct to the best of my knowledge, is binding on me and nothing has been hidden by me. I shall not claim any change or
alteration. If any of them is found to be incorrect or false, my candidature will be liable to be rejected and I shall be liable
to any penal action and / or punishment as may be deemed fit by the UG admission board.

I have gone through all the rules, information booklet, instructions for filling on-line registration form college information
sheet, notification(s), fee structure etc. and I promise to abide by them.

I fulfill the prescribed eligibility criteria relating to educational qualification etc. for the course(s) I am applying for.

I hereby agree, if admitted, to abide by the rules and regulations in force at the college or those that may hereafter be made
for administration of the college and I undertake that so long as I am a student of the college, I will do nothing either inside
or outside the college that will interfere with its orderly working and discipline.

Applicant's signature (in box)

Left thumb Right thumb

Place : ARYAN AGRAWAL

Date : RM3773

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