DIRECTORATE OF TECHNICAL EDUCATION, CHHATTISGARH, RAIPUR

APPLICATION FORM FOR ALLOTMENT / ADMISSION TO

FIRST YEAR OF FOUR - YEAR FULL - TIME DEGREE COURSES IN ENGINEERING / TECHNOLOGY FOR THE ACADEMIC YEAR 2019-2020
BASED ON PET - 2019 (IWC - 2)

APPLICATION ID : EN19640856 VERSION NO : 1 ROLL NO : 25023131

Personal Details :
Candidate's Name VINAS BANSRE
Father's / Husband's Name BISHRAM BANSRE Mother's Name SHARDA
Domicile Status Chattishgarh Category SC
Domicile State Chhattisgarh
Date of Birth 31/12/1998 Gender Male
Mother Tounge Hindi Family Income Less than 50,000
Religion Hinduism Region Rural
Belong To BPL Class No AADHAR No. 767693398869
Contact Details.
36, KURRE PARA PIRDA 2, KURRE 36, KURRE PARA PIRDA 2, KURRE
Correspondence Address PARA PIRDA 2, PIRDA 2, GSI Permanent Address PARA PIRDA 2, PIRDA 2, GSI
SAKRI BHATHA SAKRI BHATHA
State Chhattisgarh State Chhattisgarh
District RAIPUR District RAIPUR
PinCode 493111 PinCode 493111
Telephone - Mobile No 6265906246
Email-Id bkbaghmar@gmail.com Gurdian Mobile No 7771813134
Special Reservation Details :
Belong to Sainik Class No Belong to Freedom Fighter Class No
Belong to Person with Disability Class No
PET - 2019 Details :
Physics Marks 12.2450000 Chemistry Marks 7.1430000
Mathematics/Biology Marks 10.6380000 Total Marks 30.0260000
General Rank 14024 Category Rank 1701
12th Std. / HSC Details :
Physics Marks 56 / 100 (56.000%) Chemistry Marks 52 / 100 (52.000%)
Maths Marks 35 / 100 (35.000%)
Aggregate Marks 247.000 / 500 (49.400%)
Physics, Chemistry, Maths Marks 143 / 300 (47.67%)
HSC Board Name Chhatisgarh Madhyamik Siksha Mandal
HSC Roll No 2181880044 Year of Passing 2018
Name of School / Institute PLY GOVT HINDU H S SCHOOL RAIPUR
Counselling Fees Details :
Fee Amount Online Payment Rs. 300 Deposit Date 12/08/2019 10:55:06
Fee Order Reference No 640856_3051089 Fee Paid Reference No CPU0171429
List of copies of documents required to submit at Document Verification Centre (DVC)
(Original documents and photo copy of original documents along with printed application cum option form must be shown at Document Verification Center for
verification)
Sr.No. Document Name Sr.No. Document Name
1 10th Class Certificate or Birth Certificate * 2 12th Class Marksheet *
3 P.E.T. - 2019 Score Card * 4 Domicile Certificate (Only in Proforma No. 5/6/7/8) ()*
5 Caste Certificate (SC) * 6 AADHAR Card (Desirable)
Declaration
I have read Admission Rules for Technical Institute's of Chhattisgarh-2019 and on understanding these rules, I have filled the application form for consideration of submission of application form at
Document Verification Centre(DVC) for the allotment / admission to FIRST YEAR OF FOUR - YEAR FULL - TIME DEGREE COURSES IN ENGINEERING / TECHNOLOGY course for the academic year
2019-2020. The information given by me in this application is true to the best of my knowledge & belief. If at later stage, it is found that I have furnished wrong information and/or submitted false certificate(s), I
am aware that my allotment / admission shall be cancelled and I shall be subjected to legal and/or penal action as per the provisions of the law.
Place : Date :
Printed On : Aug 13 2019 5:06:22:787PM Signature of Candidate
Application Last Modified On : Aug 12 2019 10:59:38:663AM (VINAS BANSRE)
 DIRECTORATE OF TECHNICAL EDUCATION
CHHATTISGARH, RAIPUR
APPLICATION FORM FOR ALLOTMENT / ADMISSION TO
FIRST YEAR OF FOUR - YEAR FULL - TIME DEGREE COURSES IN ENGINEERING / TECHNOLOGY FOR THE ACADEMIC YEAR 2019-2020
BASED ON PET - 2019 (IWC - 2)

APPLICATION ID : EN19640856 VERSION NO : 1 ROLL NO : 25023131

Options Given By Candidate :

Preference Institute Institute Name University Status Choice Code Course Name
No Code Name
1 167 Central Institute of Plastic Engineering & Technology, Raipur CSVTU GOVERNMENT 16724 Plastic Engineering
Declaration
I have read Admission Rules for Technical Institute's of Chhattisgarh-2019 and on understanding these rules, I have filled this option form for consideration of submission of
option form at Document Verification Center (DVC) for the allotment to FIRST YEAR OF FOUR - YEAR FULL - TIME DEGREE COURSES IN ENGINEERING / TECHNOLOGY
for the academic year 2019-2020.

The information given by me in this option form is true to the best of my knowledge & belief. At later stage, if it is found that I have furnished wrong information then I am
fully aware that the option form submitted will not be altered / modified / changed in any case I will be responsible for any further consequences arises due to my mistake. I also
undertake that options filled by me are my choice, I have filled it based on my own inclination/knowledge and not due to any pressure/ignorance/unwanted influence.

I also herewith undertake that, at later stage, if it is found that I have submitted false certificate(s)/document(s), I am aware that my allotment stands canceled. Further I will be
subjected to legal and/or penal action as per the provisions of the law.
Place : Date :
Application Form Printed On : Aug 13 2019 5:06:22:787PM Signature of Candidate
Application Form Last Modified Aug 12 2019 10:59:38:663AM (VINAS BANSRE)
On :