GOVERNMENT OF TAMIL NADU

DIRECTORATE OF MEDICAL EDUCATION

SELECTION COMMITTEE
MBBS / BDS (Management Quota) Course Session :2021 - 2022 MQ
MANAGEMENT QUOTA
AR.NO :
Application No. : 902528
(To Be Assigned By the Selection Committee)
Hsc/Equivalent Reg/Roll no : 2016783334
1
Year of Passing : 2021
2 Name : ARAVINDAN V
3 Parent Name : LAKSHMI R
4 Date of Birth : 29-10-2003
5 Gender : MALE
Paste your passport size
6 Nationality : INDIAN
uploaded Photo
7 Religion : HINDU
8 Mother Tongue : TAMIL
9 Nativity : Tamil Nadu 10. Community : BC
Sub Caste with Code : Agamudayar-1
11 Certificate No : Issued Taluk -
Issued By : Issued Date :
12a) Apply for NRI Quota? : NO
b) Apply under Linguistic Minority Category? : NO
13a) Whether studied from 6th to 12th in Tamilnadu? : YES
14 Qualification Examination HSC Group Code ( Tn State only) : 2503
15 Name of the Board of Examination : Tamilnadu-Tamilnadu Board of Higher Secondary
Education
16 Passed all the subjects of HSC / Equivalent exam in no of attempts. : 1 - Passed all the subject in First Attempt
NEETUG- 2021 Details
17a) ROLL Number : 4101008452 Application Number : 210410099355 NEET Score : 293

17 b) Marks Obtained in HSC (Academic/Equivalent) Examination

Subject Register Number Month Year Maximum Mark Obtained Mark

Physics 2016783334 May 2021 100 96.07

Chemistry 2016783334 May 2021 100 93.79
Biology 2016783334 May 2021 100 91.79
Mathematic 2016783334 May 2021 100 95.06
 18 UnderGoing / Completed any professional courses : NO
a) If yes mention name of the course : NO
19 Medium Of Instruction : ENGLISH
20a) Civic School : Corporation : b) Civic Native : Corporation
21) School of Study Information
Class Year of Name of the School District State School Type
Passing
VI 2015 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC
VII 2016 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC
VIII 2016 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC
IX 2018 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC
X 2018 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC
XI 2020 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC
XII 2021 BETHEL MATRIC HR SEC SCHOOL CHENNAI TAMIL NADU SELF FINANCE MATRIC

22 Are you a First Graduate Applicant : NO

23a) Parent Occupation : Professional : b) Parent Annual Income : Rs. 1,00,001 - 2,50,000
127/C, AYYA FLATS , VGP AVENUE , DR.SEETHAPATHY
24 Address For Correspondence : NAGAR , VELACHERY , CHENNAI - 600 042 CHENNAI
TAMIL NADU -600042
25 Native District : CHENNAI : Native State : Tamil Nadu
26 Aadhar Number : 370018354318
27a) Email Id : avisu456@gmail.com : b) Pnone Number : 9791404271
28 Payment : Amount=1000.00, TrackID=IP213614999031

I do hereby solemnly affirm that the statement made and information furnished in my application form and in all the
enclosures thereto submitted by me are true. Should it however be found that any information furnished therein is untrue in
particulars, or there has been suppression of facts. I realize that I am liable for criminal prosecution and I also agree to forego
my seat in the College at any time during the course of my study.

If I failed to produce any necessary documents at any stages of counselling / admission or any wrong information furnished in
the application form, I aware that the selection committee has rights to disqualify me and remove from this year admission
and merit list.

Place :
(Signature of Applicant)
Date :
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF MEDICAL EDUCATION
SELECTION COMMITTEE

Application for Admission to MBBS / BDS (Management Quota) Course Session

:2021 - 2022

Application No. : 902528

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. First Graduate Certificate (If applicable)
6. Permanent Community Certificate Card (Permanent card / electronic form / digitally signed e-Certificate)
7. Aadhar Card
8. NEET UG 2021 Score Card
9. Nativity Certificate for the candidate who seeks admission under linguistic minority category
10. Annexure I (a) or I (b) for the candidate who seeks admission under religious/linguistic minority category
11. If NRI Candidate
1. Ward Certificate
2. Copy of NRI Status issued by the Indian Embassy of the respective country under their seal
3. Copy of Passport of the parent
4. Copy of NRE (Non-Resident External) Bank Account Pass Book of the parent
12. Nativity certificate for the candidates who have partly or completely studied outside Tamil Nadu from standard VI
to standard XII
13. Parents Certificate
1. Birth Certificate or Ration Card or Passport.
2. Study Certificate (10th or 12th or Degree Certificate)
3. Parent's Community Certificate

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.
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF MEDICAL EDUCATION
SELECTION COMMITTEE
Application for Admission to MBBS / BDS (Management Quota) Course Session
:2021 - 2022

Application No. : 902528

Recent
Passport
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DECLARATION BY THE APPLICANT

I,ARAVINDAN V( Son / Daughter / Ward) of LAKSHMI Ran applicant for MBBS / BDS (Management Quota) Course Session :2021 -
2022 hereby solemnly declare that I have not claimed Dual Nativity in this regard and I belong to BC. (Community) and sub-
caste Agamudayar-1. 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 legal proceedings / Criminal action.

Place :
(Signature of Applicant)
Date :

DECLARATION BY THE PARENT / GUARDIAN

I,LAKSHMI R(Parent / Guardian) of ARAVINDAN V an applicant for MBBS / BDS (Management Quota) Course Session :2021 -
2022 hereby solemnly declare that I 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 legal proceedings / Criminal action.s

Place :
(Signature of Parent / Guardian)
Date :

Note: Guardian can execute the above declaration,only if both the parents are not alive.
 RELIGIOUS & LINGUISTIC MINORITY CERTIFICATE
2021 - 2022 SESSION

(Candidates who claim seats in Colleges of religious & Linguistic Minority Status)

This is to certify that Thiru/Selvi. ……………………………………………….. S/o / D/o

………………………………………………………………………… has studied from Standard
………………………… to Standard ………………………… in our Institution during …………………………… to
………………………………… Academic years. He/she belong to …………………………………………. Religion
and the mother tongue of the above student is …………………………… as per the admission Register maintained in the
Institution. The above details are true and correct to the best of my knowledge.

Seal and Signature of the Principal

of the school where the candidate has
last attended.

Name of the Principal. ……………………………………………………………….

Name, full postal address and telephone number

of the Institution from where the candidate has
passed SSLC /10th Standard examination
Institution last studied:

Date:……………………………………………
 Affidavit (to be submitted by Minority Religious and Linguistic candidates)

(To be submitted in a 20/- Bond paper at the time of verification)

I, ……………………………………………………………………… son / daughter of
……………………………………………………………………………............residing at
…………………………………………………………………have appeared for NEET UG -2021 conducted by CBSE,
New Delhi with Roll Number ………………………… and Register Number ……………… and have secured
…………….. Score in the said test. I hereby solemnly declare that I belong to …………………………………….
Religion and my mother tongue is ………………………………. I have studied from 8th Standard to 12th Standard in
Tamil Nadu during ……………………. to ……………………. I have sworn to this affidavit and submitted to the Tamil
Nadu for Selection of seat under the ……………………….. Category. I declare that the above information is correct to
the best of my knowledge and belief. In case any of the above information is found to be false or incorrect, I shall forfeit
the seat allotted by the Tamil Nadu. I hold myself also, liable for civil or criminal action and the Government of Tamil
Nadu may take appropriate action against me in this behalf. I shall produce all required original documents for verification
and submit the same after allotment of seat to concerned college. I shall not produce/submit fake/concocted documents
for verification or admission.

Date :
Place :

Signature of the Candidate Deponent

Sworn Before Me.
 WARD CERTIFICATE (CHILDREN OF NON-RESIDENT INDIAN OR THEIR WARDS)
(FOR ADMISSION UNDER NRI QUOTA SEATS).
2021 -2022 SESSION

I ………………..………………….. Son of Thiru/Tmt (name of Guardian) ………………….………….. aged

……………………….. years …………….. (Date of Birth)…………... holding an ………...……… Passport and
residing at……………………………………………………..………………………………………………………….
………………………………………………………………………………………………………………………………..
……………..… Telephone No. ………………………….…… Mobile No. ……….…….……………………..… e-mail
ID:………………………………………..….……..do hereby solemnly affirm and state that, Thiru/ Tmt.…….
………………………………………… S/o/D/o of ……………………………………………………………………who
is seeking admission to Under Graduate Medical / Dental Course Through Tamil Nadu for the year 2021-2022 is my
“ward”. I would wish to state that I am the guardian of the said candidate for the entire course of study and will be legally
responsible for his/her Under Graduate Study.

Passport Details:
Passport No. …………………………. Place of issue …………………………….
Date of Issue. ………………….. Date of Validity of Passport ……………………

Bank Account Details:

Nature of Account ……………………………….……
Name of the Bank and Address …………………………………….
Relationship with the student ……………………………….

(Signature of the Guardian)

Date : ……………………..

Place.…………………….
 MQ / NRI
REGD. POST / SPEED POST/COURIER SERVICE /BY PERSON
APPLICATION FORM FOR ADMISSION TO MBBS / BDS (MANAGEMENT
QUOTA) COURSE SESSION :2021 - 2022

APPLICATION NUMBER: 902528

NEET UG 2021 ROLL NUMBER : 4101008452

NEET UG 2021 REG. NUMBER: 210410099355

NAME : ARAVINDAN V
QUALIFYING EXAMINATION : HSC
COMMUNITY : BC
NRI QUOTA : NO

From : (Candidate’s Mailing Address)

To
-------------------------------------------------------------------------------------
The Secretary
-------------------------------------------------------------------------------------
Selection Committee,
-------------------------------------------------------------------------------------
No. 162, Periyar E.V.R. High Road
-------------------------------------------------------------------------------------
Kilpauk, Chennai – 600 010.