CENTAC - Govt.

of Puducherry 04/06/19, 10)20 PM

CENTRALISED ADMISSION COMMITTEE

Government of Puducherry
APPLICATION FORM FOR ONLINE CENTAC ADMISSION - 2019 - 20

APPLICATION NUMBER   :  80100021 UG NEET Courses (M.B.B.S., B.D.S., B.A.M.S., B.V.Sc.)

Personal Details

Applicant's Name: SHRINITHI S S

Father's Name SRISARAVANAN

Gender FEMALE

Date of Birth 19-01-2002

Nationality INDIAN

Religion HINDU

Are you Puducherry Residence NO

(Having residence certificate issued by the Govt. of
Puducherry)

Region OTHERS

Category GENERAL

Special Category Not Applicable

Address Details

Email-id srisarav@gmail.com

Mobile Number 9894930380

Alternate Number 9486209790

Permanent Address Mj Hospital 6 Central Cinema street Natham, 624401.

Communication Address Mj Hospital 6 Central Cinema street Natham, 624401.

Academic Data Entry

APPLIED FOR MBBS

HSC Registration No 4627067

HSC Board Name Central Board of Secondary Education

HSC Result PASS

HSC Marks

Subjects : ENGLISH LANGUAGE MATHEMATICS/MATHEMATICS PHYSICS CHEMISTRY BIOLOGY

I

Marks : 87 61 83 79 93

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CENTAC - Govt. of Puducherry 04/06/19, 10)20 PM

Payment Details

Payment Mode: ONLINE PAYMENT

Amount Paid : ! 2000.00

Amount Total : ! 2000.00

Payment Transaction No : 19060450608252

Payment Status : SUCCESS

Attachments

Attached File Uploaded View

HSC Certificate Yes HSC Certificate

PIC Certificate Front Page No

Regional Certificate No

NRI Certificate No

Rural Certificate No

Community Certificate No

Nationality / Nativity Certificate No

Residence Certificate No

COURSE PREFERENCE DETAILS

Preference No Course Name

1 [MQ] - PONDICHERRY INSTITUTE PIMS [M.B.B.S.] - Medicine

2 [MQ] - MANAKULA VINAYAGAR MEDICAL [M.B.B.S.] - Medicine

3 [MQ] - VENKATESWARA MEDICAL [M.B.B.S.] - Medicine

Declaration :

" I hereby declare that I have carefully read the Prospectus and the Non-Disclosure agreement. All the particulars stated in this application form
are true and correct to the best of my knowledge and belief. If any of these information provided is found false/ incorrect, I shall abide by the
actions and decisions taken by the CENTAC

Signature

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