Application of Job: University Entry Scheme-2019

Application No: UIT196M000304 Application Date: 21/07/2018

1. PRIORITY

1. SSC [SSC(IT_U)] 06/2019 2. SSC [SSC{GS(X)_U}] 06/2019 3. PC [PC{GS(X)_U}] 06/2019

2. PERSONAL PARTICULARS

Name: ASHISH RANJAN Nationality: INDIAN

Father's/Mother's Name: ANJAY KUMAR SINGH Gender: MALE
Date of Birth: 27/02/1998 Guardian's Name: ---------
Identification Mark 1: MOLE ON CHEST
Identification Mark 2: ---------

EDUCATION PARTICULARS

Details of Graduation

Second Highest MAULANA ABUL KALAM AZAD

B.Tech Marks Available In : CGPA University Name :
Qualification : UNIVERSITY OF TECHNOLOGY
Computer ABACUS INSTITUTE OF
Stream : CGPA : 8.65 College Name :
Science ENGINEERING AND MANAGEMENT
In Final
Candidate Status : CGPA Percentage : 79.02 College State : WEST BENGAL
year
Candidate Type : Regular Passing Year : 2019 College District : HOOGHLY

Details of 12th Science

Subjects Total Marks Obtained Marks

English 100 89

Physics 100 78

Chemistry 100 94

Maths 100 88

Physical Education 100 95

Total Marks: 500 Marksheet Serial Number: 632201

Obtained Marks: 444 State Conduct: BIHAR
Percentage: 88.80 Board Conduct: Central Board of Secondary Education (CBSE)
 Details of 10th

Total Marks: 500 Marksheet Serial Number: 1102483

Obtained Marks: 475 State Conduct: BIHAR
Percentage: 95.00 Board Conduct: Central Board of Secondary Education (CBSE)

4. MILITARY RECORD

Have you ever been enrolled in Armed Forces before?: NO

Have you attended any Services Selection Board (SSB) before?: NO

Have you been discharged from Armed forces before?: NO

5. COMMUNICATION PARTICULARS

Details of Permanent Address Details of Correspondence Address

Address 1: VILL-USARI CHANDPURA P.O.-USARI
Pincode: 841424 Same as Permanent Address
CHANDPURA
Address 2: P.S-TARAIYA DISTRICT-SARAN Mobile No.: 7044399830
State: BIHAR Email id: ashishranjan724@gmail.com
District: SARAN

A. I hereby declare that I am unmarried, governed by nationality condition as laid down by the Government of India and have never
been debarred from appearing at any examination. I have never been arrested/ prosecuted and convicted by a criminal court or
involved in any other case registered by the Police.

B. I hereby, solemnly declare that all the statements made in the above application are true and correct to the best of my knowledge
and belief.

C. I fully understand that in the event of my information being found false or incorrect, appropriate action can be taken against me.

D. Eligibility criteria will be verified on reporting at the selection centres. If found ineligible, I understand that criminal proceedings can
be initiated against me for fraudulent entry and falsification of Government of India documents. I also accept that no TA/ DA will be
admissible to me in such cases.

6. APPLICATION FORM TO BE SIGNED BY THE DIRECTOR OF ENGINEERING COLLEGE/HEAD OF DEPARTMENT

Certified that Miss/Mr .............. is studying in this University/College/Institute and that details furnished by him in para 3 and
4 of application form have been checked with refrence to relevant records and found correct.
Place:........... Date:................ Signature(Director/HOD):..............................

CAMPUS VENUE DETAILS (TO BE FILLED IN BY THE APPLICANT)

DATE: COLLEGE VENUE: SIGN:

FOR OFFICE USE ONLY

GRADE: SIGNATURE: