Uttar Pradesh University of Medical Sciences

C.P.P.N.E.T. – 2020 Application Form

SESSION 2020-21
URN # 20G0017402 Appl. Date : 28 December, 2020 04:11 PM

1. Candidate Name : PRATIBHA BHARTI

2. Father's Name : RAJ PAL BHARTI
3. Mother's Name : VIMLA BHARTI
4. Date of Birth : 15-Dec-1995 5. Gender : FEMALE
6. Category : S.C. 7. Sub Category : Not Applicable

8. Other Category : Not Applicable 9. AADHAAR : 842973143300

10. Domicile : Uttar Pradesh 11. Dom. Cert. : 204192016955
12. Religion : Hindu 13. Minority : NO
14. Nationality : INDIAN 15. EWS Status: Not Applicable

16. Address for Correspondance : 17. Permanent Address :

6 DISTRCIT HOSPITAL BAREILLY 6 DISTRCIT HOSPITAL BAREILLY
Bareilly Bareilly
Uttar Pradesh Uttar Pradesh
PIN Code : 243003 PIN Code : 243003

18. Mobile : 9457554034 19. Email : pratisngh786@gmail.com

20. Payment Details: Paid Rs.500.00 on 28/12/2020 Ref# 11934363531 Bank Ref: MAST - 036319008632
21. Qualifications

Examination Board/University Year Roll No. Max. Mrk. Obt. Mrk.

Intermediate U.P. Board of High School & Intermediate Education, A... 2014 0773289 500 315
Subjects/Stream : Physics,Chemistry,Biology,English

Subject Obtained Marks Max Marks Percentage %

Physics 56 100 56.00
Chemistry 71 100 71.00
Biology 61 100 61.00
English 69 100 69.00
Hindi 58 100 58.00

22. Test Centre Preference

First Preference Second Preference Third Preference Fourth Preference

(Code 04) Lucknow (Code 03) Kanpur (Code 02) Agra (Code 01) Noida

23. Test Paper Details

Paper Title Paper Details
Paper-I (A, B and C) (a) Physics / (b) Chemistry / (c) Biology

Printed: Monday, December 28, 2020 04:30 PM Page: 1/2

 Uttar Pradesh University of Medical Sciences
C.P.P.N.E.T. – 2020 Application Form
SESSION 2020-21
URN # 20G0017402 Appl. Date : 28 December, 2020 04:11 PM

24. Provisonally Eligible for following courses

1. Bachelor of Science Laboratory Techniques (BMLT) 2. Bachelor of Physiotherapy (BPT)

3. Bachelor of Science in Radiological Imaging Technique... 4. Bachelor of Optometry (B.Optom.)

5. Bachelor of Pharmacy (B.Pharm.) 6. Bachelor of Science in Nursing

7. Diploma in General Nursing and Midwifery (GNM) 8. Diploma in Auxillery Nurse and Midwifery (ANM)

9. Diploma in OT Technician (DOT) 10. Diploma in Optometry Technician (D.Optom.)

11. Diploma in Physiotherapy Technician (DPT) 12. Diploma in Dialysis Technician (DDT)

13. Diploma in CT Scan Technician (D.C.T.Scan) 14. Diploma in Cardiology Technician (D.C.T.)

15. Diploma in M.R.I. Technician (D.M.R.I.) 16. Diploma in Emergency and Trauma Care Technician (...

17. Diploma in Blood Transfusion Technician (D.B.T.)

Declaration

I declare that I have never been convicted for any criminal act and that there is no case pending
against me in the court of law. I also declare that I have never been caught using Unfair Means or
any Disciplinary action has been taken against me. If I was charged for using Unfair Means, the
punitive duration is over and charges have been cleared. I have read carefully and have understood
all rules as mentioned in the University Rules and Admission Brochure. Furthermore I also declare
that if my application is found to contain incorrect/false information regarding my Name, Birth Date,
Gender, Religion, Domicile, Weightage, Caste, Horizontal Reservation, Marks obtained or any other
field, my application is liable to get cancelled, and I will have no objection in getting disqualified for
admission to the concerned course/college.

Signature of Parent/Guardian Signature of Candidate

Date: Date:

Document Uploaded Checklist

NOTE: These documents have been uploaded with the application

Recent Passport Sized Photograph

Signature
10th (High School) Marksheet / Birth Certificate
12th (Intermediate) Marksheet
Domicile Certificate for Uttar Pradesh (if 10th or 12th done from outside Uttar Pradesh)
Caste Category / Economically Weaker Section Certificate for Uttar Pradesh

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