North Eastern Regional Institute of Science and

Technology
Application Form For BASE Admission 2023 (NEE-I)

Application No. : BASE23000023

Date : 14/07/2023

Personal Details :
First Name RENNY
Middle Name NATHAN
Last Name SIANGBUD
Date of Birth 14/07/2006
DOB Proof Not Submitted
Gender Male
Email ID rennydiengdoh@gmail.com
Mobile Number 9362548090
Are you Differently Abled? No
PWD Certificate Not Submitted
Nationality INDIAN
Religion CHRISTIAN
Blood Group B+
Aadhar Number 749962827904
Is Alumnus of NERIST? No
Extra Curricular Activity Choice NSS

Category :
Category ST

Address :
Address NONGMENSONG
Country INDIA
State Meghalaya
District East Khasi Hills
City Shillong
Pin Code 793019
Same as Home Address Yes

Correspondence Address :
Address NONGMENSONG
Country INDIA
State Meghalaya
District East Khasi Hills
Pin Code 793019

X Details :
Year of Passing 2023
Overall % 81.6
Board/University ICSE
Medium English
X Marksheet Not Submitted
X Certificate Not Submitted

NEE :
NEE Roll Number 111101091
NEE Reservation Code Applied 4106
NEE Reservation Code Selected MEG_UR
NEE State Meghalaya

Bank Details :
Account Number 37975378300
IFSC Code SBIN0007885
Bank Name STATE BANK OF INDIA

1
Application No. : BASE23000023
Date : 14/07/2023

Bank Branch POLO

Bank Account (Cancelled Cheque/Passbook) Passbook.pdf

Father Details :
Name BESTARLAND NATHAN DIENGDOH
Mobile Number 9863086145
Email ID rennydiengdoh@gmail.com
Occupation OTHER
Address NONGMENSONG

Mother Details :
Name RILIANCY SIANGBUD
Mobile Number 9436124327
Email ID rennydiengdoh@gmail.com
Occupation OTHER
Address NONGMENSONG

Legal Guardian Details :

Name LENNY NATHAN SIANGBUD
Mobile Number 9077598933
Email ID lennynathans4@gmail.com
Occupation STUDENT
Address NONGMENSONG

Family Income Details :

Monthly Family Income 20000
Family Income Certificate Not Submitted

School/Institute/University Leaving Certificate Not Submitted

Migration Certificate Not Submitted

PRC/GEC Not Submitted
Category (SC/ST/OBC-NCL/EWS) Certificate Not Submitted

Aadhaar Card Not Submitted

Medical Fitness Certificate (as per proforma) Not Submitted

Online Anti-Ragging Undertaking Not Submitted

Any Other 1 Not Submitted
Any Other 2 Not Submitted

Preferences :
PREFERENCE(1) NERIST:AE:AE
PREFERENCE(2) NERIST:CE:CE
PREFERENCE(3) NERIST:ME:ME
PREFERENCE(4) NERIST:ECE:ECE
PREFERENCE(5) NERIST:EE:EE

Declaration :
I certify that all the information provided by me in this form is correct to the best of my knowledge. I understand
that any willful mispresentation of facts will result in my dismissal from the Institute. I shall abide by all the rules
and regulation of the Institute, if admitted. I also declare that I will not indulge in any form of ragging/any type of
offense/criminal cases during the course of my study in NERIST, if admitted, and I agree to abide by the
punishment given to me if I am found guilty of ragging/any offense/criminal cases.

2
Application No. : BASE23000023
Date : 14/07/2023

Date : 14-07-2023 Place : SHILLONG

Form Submission Date : Signature

14-07-2023