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DIRECTORATE OF TECHNICAL EDUCATION, CHHATTISGARH, RAIPUR

APPLICATION FORM FOR ALLOTMENT/ADMISSION TO FIRST YEAR OF FOUR-YEAR FULL-TIME


DEGREE COURSES IN ENGINEERING / TECHNOLOGY FOR THE ACADEMIC YEAR 2014-2015
Based on CG PET-2014
APPLICATION ID : EN14113412 VERSION NO : 2 PET-2014 ROLL NO : 25081383
Personal Details :
Candidate's Name JAYENDRA KUMAR
Father's Name SANJAY KUMAR Mother's Name BASANTI BAI
Domicile Status Chhattisgarh
Domicile
Category OBC
Date Of Birth September 22, 1996 Gender Male
Mother Tounge Hindi Family Income ( ) <1,00,000
Religion Hindu Region Rural
Belong to BPL Class No
Correspondence
Address
S/o MR. SANJAY
KUMAR VILLAGE
POST BARBANDA VIA
MANDHAR COLONY
RAIPUR
Permanent
Address
S/o MR. SANJAY
KUMAR VILLAGE
POST BARBANDA VIA
MANDHAR COLONY
RAIPUR
State Chattisgarh State Chattisgarh
District Raipur District Raipur
Block Dharsiwa Block Dharsiwa
Pin Code 493111 Pin Code 493111
Telephone 1 () Telephone 2 ()
E-Mail ID Mobile No 9617348399, 9926297892
Special Reservation Details :
Belong to Sainik Class No Belong to Freedom Fighter Class No
Belong to Person with Disability Class No
PET-2014 Details :
Physics Marks 17.347 Chemistry Marks 11.000
Mathematics Marks 19.388 Total Marks 47.735
General Rank 9611 Category Rank 3994
12th Std./H.S.C. Details :
Physics Marks 57.00 / 100.00 Chemistry Marks 73.00 / 100.00
Mathematics Marks 56.00 / 100.00 Aggregate Marks 283.00 / 500.00
Physics, Chemistry and Mathematics Marks 186.00 / 300.00
H.S.C. Board Chhatisgarh Board of Secondary Education (CGBSE), Raipur
H.S.C. Roll No. 2141803461 Year of Passing 2014
Name of School/Institute GOVT H S SCHOOL MANDHAR RAIPUR
Counseling Fees Details :
Challan Amount ( ) 300/- Challan Date July 7, 2014
Bank Name State Bank of India Branch Name BAIRAN BAZAR
City Name RAIPUR
List of copies of Documents required to submit at Document Verification Centre (Originals
must be shown at Document Verification Centre for Verification) :
Sr. No. Document Name
1. Rs. 300/- Challan f or Counselling Fee.
2. S.S.C. (Std.X) Mark Sheet.
3. H.S.C. (Std.XII) / Diploma Mark Sheet.
4. PET-2014 Score Card.
5. Domicile Certiif icate issued by any Authorisied/Competent Of f icer in Prof orma - 5 / 6 / 7 / 8 as Applicable.
6. Permanent Caste Certif icate (Leaving Creamy Layer) in Prof orma - 2.
7. Caste Verif ication Certif icate.
Declaration
I have read Information Brochure and all the rules of allotment and on understanding these
Rules, I have filled this Application Form for consideration of submission of application form at Document
Verification Centre(DVC) for the Allotment to Engineering / Technology Course for the academic Year 2014-
2015. The information given by me in this application is true to the best of my knowledge & belief. If at later
stage, it is found that I have furnished wrong information and/or submitted false certificate(s), I am aware
that my allotment stands cancelled. Further I will be subject to legal and/or penal action as per the provisions
of the law.
Place : Date :
Printed On : July 7, 2014 12:20:52 PM
Application Last Modified On : July 7, 2014 12:20:39 PM
Signature of Candidate
(JAYENDRA KUMAR)

DIRECTORATE OF TECHNICAL EDUCATION, CHHATTISGARH, RAIPUR
OPTION FORM FOR ALLOTMENT/ADMISSION TO FIRST YEAR OF FOUR-YEAR FULL-TIME
DEGREE COURSES IN ENGINEERING / TECHNOLOGY FOR THE ACADEMIC YEAR 2014-2015
Based on CG PET-2014
APPLICATION ID : EN14113412 VERSION NO : 2 PET-2014 ROLL NO : 25081383
Options Given By Candidate :
Preference
No
Institute
Code
Institute Name
University
Name
Status
Choice
Code
Course Name
1 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11405
Electrical & Electronics
Engineering
2 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11410 Mechanical Engineering
3 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11407
Electronics & Tele
Communication
Engineering
4 EN114 Disha Institute of Management & Technology, Raipur CSVTU Private 11404
Computer Science &
Engineering
Declaration
I have read Information Brochure and all the rules of allotment and on understanding these
Rules, I have filled this Option Form for consideration of submission of Option Form at Document Verification
Centre(DVC) for the allotment to Engineering / Technology for the academic Year 2014-2015.
The information given by me in this Option Form is true to the best of my knowledge & belief.
At later stage, if it is found that I have furnished wrong information then I am fully aware that the Option Form
submitted will not be altered/modified/changed in any case and I will be responsible for any further
consequences arises due to my mistake. I also undertake that options filled by me are may own choice, I have
filled it based on my own inclination/knowledge and not due to any pressure/ignorance/unwanted influence.
I also herewith undertake that, at later stage, if it is found that I have submitted false
certificate(s)/document(s), I am aware that my allotment stands cancelled. Further I will be subjected to legal
and/or penal action as per the provisions of the law.
Place : Date :
Option Form Printed On : July 7, 2014 12:20:52 PM
Option Form Last Modified On : July 7, 2014 12:20:39 PM
Signature of Candidate
(JAYENDRA KUMAR)

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