GOVERNMENT OF TAMIL NADU

DIRECTORATE OF MEDICAL EDUCATION

TAMIL NADU MBBS / BDS ADMISSIONS 2019 GQ
GOVERNMENT QUOTA

Application No. : 502243

Personal Information
Name vignesh D Nativity Tamil Nadu
Parent Name dhananjaya reddy Religion HINDU
25/1, plot no 10 v.g.rao nagar c
sector 3rd cross street. katpadi.
Permanent Address Community OC
vellore. pin code: 632007. tamil nadu
VELLORE TAMIL NADU -632007
Mobile Number 8610826344 Caste Name - Code Others-500
Email [email protected] Aadhar Number 543180593644
Date of Birth 29-08-1999 Nationality INDIAN
Gender MALE
Special Reservation Information
Eminent Sports Person NO Differently Abled Person NO
Exservicemen YES
School of Study Information
Studied VIII, IX, X, XI & XII Std. in Tamil Nadu School of Study YES
Class Year of Passing Name of the School District State
sunbeam cbse higher secondary school.
VI Std. 2011 VELLORE TAMIL NADU
katpadi
sunbeam cbse higher secondary
VII Std. 2012 VELLORE TAMIL NADU
school.katpadi
sunbeam cbse higher secondary
VIII Std. 2013 VELLORE TAMIL NADU
school.katpadi
sunbeam cbse higher secondary
IX Std. 2014 TIRUPPUR TAMIL NADU
school.katpadi
sunbeam cbse higher secondary
X Std. 2015 VELLORE TAMIL NADU
school.katpadi
sunbeam matric higher secondary school.
XI Std. 2016 VELLORE TAMIL NADU
katpadi
sunbeam matric higher secondary school.
XII Std. 2017 VELLORE TAMIL NADU
katpadi

NEET Information
NEET Roll Number NEET Reg No NEET Mark
411401617 190410053912 378
Academic Information
Qualifying Examination HSC
Name of the Board of Examination Tamilnadu-Tamilnadu Board of Higher Secondary Education
HSC/Equivalent Register Number & Year : 1710705999 - 2017
HSC Group & Group Code : HSC Academic - 103
Undergoing / Completed any Professional courses. : NO
Passed all the subjects of HSC / Equalent examination in No. of attempts : 1 - Passed all the subject in First Attempt
Marks Obtained in HSC (Academic/Equivalent) Examination
Subject Register Number Month Year Maximum Mark Obtained Mark
Physics 1710705999 Mar 2017 200 189
Chemistry 1710705999 Mar 2017 200 199
Biology 1710705999 Mar 2017 200 194
Other 1710705999 Mar 2017 200 190

Civic Information
Mother Tongue TELUGU Civic Native Town Panchayat
Medium Of Instruction ENGLISH Civic School Village Panchayat
Parent Occupation Central Govt. Native District VELLORE
Annual Income Rs. 2,50,001 - 6,00,000
My Brother / Sister availed First
First Graduate Tuition Fee Concession NO NO
Graduate Tuition Fee 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. : 502243

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. HSC Hall Ticket

6. Permanent Community Certificate Card (Permanent card / electronic form / digitally signed e-Certificate)
7. Income Certificate of the Parent if applicable

8. Nativity Certificate if applicable

9. NEET UG 2019 Score card.

10. Special Reservation Form For Sports and relevant certificates if applicable

11. Special Reservation Form For Ex-serviceman and relevant certificates if applicable
12. Special Reservation Form For Differently Abled and relevant certificates if applicable

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. : 502243

Recent
Passport
size
Photo

DECLARATION BY THE APPLICANT

I,vignesh D( Son / Daughter / Ward) of dhananjaya reddy an applicant for MBBS / BDS 2019-2020session hereby solemnly declare thatI have
not claimed Dual Nativity in this regard and I belong toOC. (Community) and sub-caste Others-500. 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 criminal prosecution.

Place :
(Signature of Applicant)
Date :

DECLARATION BY THE PARENT / GUARDIAN

I,dhananjaya reddy (Parent / Guardian) ofvignesh D an applicant for MBBS / BDS course 2019-2020 session hereby solemnly declare thatI 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 criminal prosecution.

Place :
(Signature of Parent / Guardian)
Date :

Note: Guardian can execute the above declaration,only if both the parents are not alive.
 A. R. No.
APPLICATION NO : 502243
(For office use only.)

MBBS / BDS 2019-2020 SESSION

SPECIAL CATEGORY FORM – I

CODE NO. CATEGORY OF SPECIAL RESERVATION

01 SON / DAUGHTER OF EX-SERVICEMEN

ORTHOPAEDICALLY PHYSICALLY
03
DISABLED

Name of the Candidate with Address:

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PINCODE:------------------------------------------------------------------------
MOBILE:-------------------------------------------------------------------------

SON / DAUGHTER OF ORTHOPAEDICALLY

Special Category
EX-SERVICEMEN PHYSICALLY DISABLED
applied for
(Encircle a Code)
01 03

SIGNATURE OF THE CANDIDATE

(For Instructions see overleaf)

 INSTRUCTIONS

1. The Special Category form is to be sent along with the application in the same cover.

2. Candidate should enclose DD drawn in favour of “The Secretary, Selection Committee, Kilpauk” payable at Chennai .
The Name of the candidate, Application No.& Address with mobile number should be written on the reverse of the
DD.

3. Candidates should enclose relevant certificates obtained from the competent authority.

4. Application without the relevant certificates will be summarily rejected without intimation to the candidate.

Table showing the Item No., Code No., Category of the Special Category and Number of seats.

CODE NO. CATEGORY OF SPECIAL RESERVATION Number of seats

01 SONS & DAUGHTERS OF EX-SERVICEMEN 5

03 ORTHOPAEDIALLY PHYSICALLY DISABLED 5% of the Total seats

G. O. (Rt) No. 145, HE (J1) Dept., Dated 16-05-2008

5% of the Total seats under Single Window systems.
 GQ
REGD. POST / SPEED POST/COURIER SERVICE /BY PERSON
APPLICATION FORM FOR ADMISSION TO MBBS / BDS COURSE IN
GOVERNMENT COLLEGES & GOVERNMENT QUOTA SEATS IN
SELF-FINANCING MEDICAL / DENTAL COLLEGES IN TAMIL NADU
2019-2020 SESSION

APPLICATION NUMBER: 502243

NEET UG 2019 ROLL NUMBER: 411401617

NEET UG 2019 REG. NUMBER: 190410053912

NAME : vignesh D
QUALIFYING EXAMINATION : HSC

COMMUNITY : OC
SPECIAL CATEGORY : EXSERVICEMEN

From : (Candidate’s Mailing Address) To

------------------------------------------------------------------------------------- The Secretary
-------------------------------------------------------------------------------------
Selection Committee,
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No. 162, Periyar E.V.R. High Road
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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.