2/19/2019

Application for UET-2019

[Opted Test Mode :PEN - PAPER (OMR BASED)]

REGISTRATION NO: BHU00561598135 PAYMENT ID: BHUU55615980482f

IDENTIFICATION TYPE : Aadhaar Card IDENTIFICATION NO. Not Applicable for Aadhaar Card

Course Code & Name: (135) B Sc. Ag. /B.Sc. Ag. RGSC
पाठय म का नाम :
Candidate Name: KAMLESH SHAH
आवेदक का नाम :
Father's Name: BANARASI GAUR
िपता का नाम :
Mother's Name: MAYA DEVI
माता का नाम:
Father's / Mother's Mobile
Number:
िपता / माता का मोबाइल नंबर :
Date of Birth: 02. October .1998
ज ितिथ :

Sex/िलंग: MALE Category/वग: ST

Blood Group: Do you claim Reservation for
ड ुप : Economically Weaker Section (EWS) ?
Physically Challenged: NO Employee's Ward: NO
शारी रक िवकलां गता: कमचारी पु पु ी :

Indian Sports Seat: NO

Nationality/रा ीयता :
ोट् स सीट :
Religion/धम: HINDU

Address For Correspondence प ाचार का पता Permanent Address थायी पता

Name: KAMLESH SHAH Guardian's Name (If
आवेदक का नाम Applicable)
Nuruddin Shahid (Dihwa) Address (पता ) : Nuruddin Shahid (Dihwa)
Address (पता ) :
Phulwariya Phulwariya

Saraiya Saraiya
Varanasi District (िजला): Varanasi
District (िजला):
Uttar Pradesh State (रा ): Uttar Pradesh
State (रा ):
221106 Pin (िपन) : 221106
Pin (िपन) :
Ph. No. with STD Code Ph. No. with STD Code
Fax No.
Mobile No. (मोबाइल नंबर ) 8565962121
Mobile No. (मोबाइल नंबर) 8565962121
Email kamleshshahvns@gmail.com

Distance of your Residence from 8-19 Annual Income of your Less than 2,00,000
BHU . Parents/Guardians in Rs.

Test Center Preference परी ा के व रयता Opted Test Mode : PEN - PAPER (OMR BASED)
Preference - 01 Varanasi [ Uttar Pradesh ] Preference - 04 Gorakhpur [ Uttar Pradesh ]
Preference - 02 RGSC Barkhachcha [ Uttar Pradesh ] Preference - 05 Lucknow [ Uttar Pradesh ]
Preference - 03 Allahabad [ Uttar Pradesh ]

Signature Uploaded by
the candidate
अ थ ारा अपलोडे ड
ह ा र

It is hereby confirmed that I have carefully read the concerned Information Bulletin available on the BHU's Entrance Test Portal (www.bhuonline.in) before filling up the Application Form.
I hereby solemnly affirm that the information furnished in this Online Application Form is true and correct to the best of my lnowledge and belief and no material information has been concealed or
suppressed. If any information is found to be false, incorrect or misleading, the Banaras Hindu University shall have the authority to cancel my candidature / admission without any further enquiry
or notice.
I undertake that, if admitted, I shall abide by the UGC Regulations on Curbing the Menace of Ragging, 2009, Ordinances governing the discipline of students of banaras Hindu University and
such other Rules, Ordinances and Regulations that may be framed by the Banaras Hindu University/ UGC from time to time.
I further undertake that the preference for the Test center, Courses, Domicile and the categories to which I belong as indicated by me in the online application form shall be irrevocable.

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