Chaudhary Charan Singh University, Meerut [ Computer Copy ]

Examination Form for Traditional MBBS

Supplementary
1. Course Name : M.B.B.S. IInd Prof.
2. Roll No. : 194322095 3. Enrolment No. : 1900464
4. College Name : S.M.M.H MEDICAL COLLEGE, AMBALA ROAD, PILAKHNI, Form No:220700126
SAHARANPUR
5. Type of Exam : Back Exam 6. Admitted Through :: NEET UG
7. Name of the Candidate : YATENDRA KUMAR GONIA
8. Father`s Name : RAVINDRA KUMAR
9. Mother`s Name : KUSUM DEVI
10. Nationality : INDIAN 11. Medium of Exam : ENGLISH
12. Date of Birth : 15/07/1999 13. Sex : Male
14. Original Resident of : U.P. 15. Kashmiri Migrant : No
16. Caste : SC (102)
17. State from where Graduated : NA
18. Do you have Domicile Certificate of U.P. State: Yes Signature of Candidate

19. Permanent Address
20. Present Address
21. Phone/Mobile No.
22. Email ID
: VILLAGE GADEENA POST GADEENA, MEERUT, MEERUT, Pin :
250401
: VILLAGE GADEENA POST GADEENA, MEERUT, MEERUT, Pin :
250401
: 9639313125
: Yatendra1999gonia@gmail.com

23. Name of Subjects

S.No. Name of the Papers Code No.
1 Pathology-I 201
2 Pathology-II 202
3 Microbiology-I 203
4 Microbiology-II 204
5
6
7
8

24. Description of Examination:

Name of Examination Year Name of the Board/University Subjects Taken Mrks Max.
obt. Mrks
High School 2015 UP BOARD ALLAHABAD HINDI ENGLISH MATH 472 600
SCIENCE SST DRAWING
Intermediate 2017 UP BOARD ALLAHABAD PCB 380 500
Graduation ()
Post Graduation()

Page 1/4 Print Date : 2022-07-18 21:12:53

Course : M.B.B.S. IInd Prof.
Type of Exam : Back Exam From No. : 220700126

25. Give details of marks obtained in previous examination Result

Part Roll No. Year Result Obtained Marks Maximum Marks
2 194322095 2022 FAIL 478 900

26. Detail of punishment for U.F.M. if any, imposed in any previous examination :
Name of the Class : Punishment Details :
Roll No : Year : Name of Centre :

27. If last examination passed from other university give the details of migration certificate from that university :

28. If you are employed , give the details of "No Objection Certificate" :

29. Whether Doing Ph.D. or any other degree of any other University in India/Abroad, you may state full particulars :

30. If Migration certificate is enclosed from another university/Board. mention its no. & date :

31. Participation in Sports:- Level of Game/Sports :

32. Checklist (Attached Documents)

Marksheet of High School : Yes Marksheet of Intermediate : Yes Marksheet of Graduation : No
Marksheet of Post Graduation : No Residence/Domicile Certificate : Yes Handicap Certificate : No
Caste Certificate :Yes Migration Certificate : No No objection certificate : No

Any other certificate 1. 2.

Declaration
I YATENDRA KUMAR GONIA(220700126), S/o RAVINDRA KUMAR hereby declare that the information given in the application form
is true to the best of my knowledge and belief. In case any information is found false / untrue, cancel my admission / exam form, for
which no claim of refund of fee would be raised by me, in future also, if any particular submitted are found to be untrue / false, the
university can cancel my degree.

Detail of Examination Fee

Transaction No. : 70002047101 Date : 18/07/2022
Total Fees : Rs. 4090/- Payment Status : PAID

Date:___________________
Place:___________________ (Full Signature of the Applicant)

Certificate of the Principal

YATENDRA KUMAR GONIA, S/o RAVINDRA KUMAR has been registered for Regular examination. All the entries in the exam from,
marksheets and other certificates attached have been duly checked and this is certified that he/she is eligible for examination as per
university rule and his/her examination form is being forworded.

Date:___________________
Sign of the checker :___________________ (Full Signature of the Principal with stamp)

Page 2/4 Print Date : 2022-07-18 21:12:53

 Chaudhary Charan Singh University, Meerut [ University Copy ]
Examination Form for Traditional MBBS
Supplementary
1. Course Name : M.B.B.S. IInd Prof.
2. Roll No. : 194322095 3. Enrolment No. : 1900464
4. College Name : S.M.M.H MEDICAL COLLEGE, AMBALA ROAD, PILAKHNI, Form No:220700126
SAHARANPUR
5. Type of Exam : Back Exam 6. Admitted Through :: NEET UG
7. Name of the Candidate : YATENDRA KUMAR GONIA
8. Father`s Name : RAVINDRA KUMAR
9. Mother`s Name : KUSUM DEVI
10. Nationality : INDIAN 11. Medium of Exam : ENGLISH
12. Date of Birth : 15/07/1999 13. Sex : Male
14. Original Resident of : U.P. 15. Kashmiri Migrant : No
16. Caste : SC (102)
17. State from where Graduated : NA
18. Do you have Domicile Certificate of U.P. State: Yes Signature of Candidate

19. Permanent Address
20. Present Address
21. Phone/Mobile No.
22. Email ID
: VILLAGE GADEENA POST GADEENA, MEERUT, MEERUT, Pin :
250401
: VILLAGE GADEENA POST GADEENA, MEERUT, MEERUT, Pin :
250401
: 9639313125
: Yatendra1999gonia@gmail.com

23. Name of Subjects

S.No. Name of the Papers Code No.
1 Pathology-I 201
2 Pathology-II 202
3 Microbiology-I 203
4 Microbiology-II 204
5
6
7
8

24. Description of Examination:

Name of Examination Year Name of the Board/University Subjects Taken Mrks Max.
obt. Mrks
High School 2015 UP BOARD ALLAHABAD HINDI ENGLISH MATH 472 600
SCIENCE SST DRAWING
Intermediate 2017 UP BOARD ALLAHABAD PCB 380 500
Graduation ()
Post Graduation()

Page 3/4 Print Date : 2022-07-18 21:12:53

Course : M.B.B.S. IInd Prof.
Type of Exam : Back Exam From No. : 220700126

25. Give details of marks obtained in previous examination Result

Part Roll No. Year Result Obtained Marks Maximum Marks
2 194322095 2022 FAIL 478 900

26. Detail of punishment for U.F.M. if any, imposed in any previous examination :
Name of the Class : Punishment Details :
Roll No : Year : Name of Centre :

27. If last examination passed from other university give the details of migration certificate from that university :

28. If you are employed , give the details of "No Objection Certificate" :

29. Whether Doing Ph.D. or any other degree of any other University in India/Abroad, you may state full particulars :

30. If Migration certificate is enclosed from another university/Board. mention its no. & date :

31. Participation in Sports:- Level of Game/Sports :

32. Checklist (Attached Documents)

Marksheet of High School : Yes Marksheet of Intermediate : Yes Marksheet of Graduation : No
Marksheet of Post Graduation : No Residence/Domicile Certificate : Yes Handicap Certificate : No
Caste Certificate :Yes Migration Certificate : No No objection certificate : No

Any other certificate 1. 2.

Declaration
I YATENDRA KUMAR GONIA(220700126), S/o RAVINDRA KUMAR hereby declare that the information given in the application form
is true to the best of my knowledge and belief. In case any information is found false / untrue, cancel my admission / exam form, for
which no claim of refund of fee would be raised by me, in future also, if any particular submitted are found to be untrue / false, the
university can cancel my degree.

Detail of Examination Fee

Transaction No. : 70002047101 Date : 18/07/2022
Total Fees : Rs. 4090/- Payment Status : PAID

Date:___________________
Place:___________________ (Full Signature of the Applicant)

Certificate of the Principal

YATENDRA KUMAR GONIA, S/o RAVINDRA KUMAR has been registered for Regular examination. All the entries in the exam from,
marksheets and other certificates attached have been duly checked and this is certified that he/she is eligible for examination as per
university rule and his/her examination form is being forworded.

Date:___________________
Sign of the checker :___________________ (Full Signature of the Principal with stamp)

Page 4/4 Print Date : 2022-07-18 21:12:53