Sr. No.

(As shown in display list)_________________

OPTION FORM FOR ADMISSION TO MBBB/BDS COURSES UNDER NEET UG-2019
University Registration ID no.__________________ Dated________________
(To be filled by the Candidate in his / her own handwriting)
1. Category applied for _____________________________________________________

2. NEET Roll No ___________________ 3. NEET Marks ______________

4. NEET Rank ___________________ 5. NEET Percentile ______________
6. Name of the Candidate __________________________________________________
7. Father's Name __________________________________________________
8. Date of Birth __________________________________________________
9. Age as on 31.12.2019 __________________________________________________
10. Name of School & State 10+1 ______________________________________________________
from where +1 & +2 10+2 ______________________________________________________
Passed
11. Marks in 10+1 and 10+2:
Marks obtained/ Total Marks
Class Physics Chemistry Biology English Total of PCB
Passing Year
Obt. Out Obt. Out Obt. Out Obt. Out Obt. Out %age
of of of of of
10+1
10+2
12. Aadhaar Card No. ______________________ Mobile No.__________________
13. Permanent Address

14. Email-ID (valid) __________________________________________________

15. Resident State __________________________________________________
16. Category Under Resident __________________________________________________
State as per PB.Govt.
letter no.1/3/95-3PP
II/9619 dated 06.06.1996
17. Issuing authority for grant __________________________________________________
of Residence certificate
18. If seat allotted/joined in
Yes No
other state for admission
to MBBS/BDS Course
19. If yes, Name of the State All India Counseling ____________________________________
allotted/joined for
admission State/UT Counseling___________________________________
20. Whether applied under NRI/OCI/PIO in Yes No
centralized Counseling (Tick Yes/No)
UNDER TAKING / SELF DECLARATION BY THE CANDIDATE
Certified that I_________________________________________S/o Mr./Mrs______________________________
resident of ________________________________________ do hereby undertake that:-
1. That I am a citizen of India.
2. That I have/had obtained the benefit of Residence for admission in MBBS/BDS courses in any other
State/UT except central counseling by MCC / DGSE.
3. a) That I have/had been allotted/joined seat elsewhere in any other State/UT for admission to MBBS/BDS
Courses, session 2019 in State Quota Counseling.
Or
b) That I have/had not been allotted/joined seat elsewhere in any other State/UT for admission to
MBBS/BDS Courses, session 2019 in State Quota Counseling.
4. That the above said information is true to the best of my knowledge and nothing is concealed therein. If at
any stage, the information provided is found false/wrong, the admission of my son/daughter/ward is liable to
be cancelled.

Thumb Impression
(Left in case of male/Right in case of female)
Signature of Candidate
 (TO BE CHECKED BY THE OFFICE)
Remarks by the Checker Signature
Checking Officer
NEET-UG-2019 Result Card
1.
Matric - Certificate for checking date of
2.
Birth (10TH )
3. 10+1 Detail Marks Card (DMC)

4. 10+2 Detail Marks Card (DMC)

Schooling Certificate of +1 & +2
5.
(Last Attendant)
Residence Certificate as per PB.Govt. letter
6.
no.1/3/95-3PP II/9619 dated 06.06.1996

7. Certificate of reserved
category (ies)
8. Affidavit (Applicable to Sikh Minority
Candidate)
9. Exemption certificate for doing 10+1 & 10+2
from outside Punjab ( If applicable)
10. Bank Challan Form for submission of
Admission Application Fee

______________________________________________________Signature of Incharge Checking Board.

OPTION FOR ADMISSION
(to be filled before the Selection Committee)
a) Certified that I have been fully aware about the vacant seats and I have also been fully explained by the
Seleciton committee about the vacanct seats at my turn in merit and the same has been displayed
outside as well as in the Selection Committee Room.
b) I hereby surrender my seat in ____________ Course session 2019 at ________________________
(MBBS/BDS) (Name of the College)
under ___________________ category of ______________________ quota.
(Name of the Category) (Government / Management)

And/or
c) I hereby accept admission in ____________ Course session 2019 at ________________________
(MBBS/BDS) (Name of the College)
under ___________________ category under ____________________________quota.
(Name of the Category) (Govt./Management)

(Signature of the Candidate)

d) I am not willing to opt any seat available at my turn and willingly forgo the available seats in
today’s counselling for the reason :________________________________________________

Time : _________________ (Signature of the Candidate)

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MEMBER MEMBER MEMBER MEMBER MEMBER CHAIRPERSON