To
The Principal.
Sarjug Dental Collage & Hospital
Mata R. Devi Dental Hospital & Jogender Memorial Medical Hospital Hospital Road , Laheriasarai Darbhanga (Bihar ), Pin : 846003
Courses Name
First Name
Date of Birth
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2050
2049
2048
2047
2046
2045
2044
2043
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Category
SELECT
General
OBC
General PH
Schedule CasteSchedule TribeBuddhist
Other Minority
Last Name
Nationality
Indian
Foreign
Student Mobile No.
Email ID
Gender
Male
Female
Fathers Name
Religion
HINDUISM
ISLAM
CHRISTIANITY
SIKHISM
BUDDHISM
JAINISM
ZOROASTRIANISM
JUDAISM
Father's Occupation
Identification Mark
Father Email ID
Mother's Name
Parent Annual Income
Guardian Contact (in case Father & Mother are not alive)
Guardian Name
Guardian Occupation
Guardian Mobile No
Relationship Type
Correspondence Address
State
SELECT -----
ANDAMAN AND NICOBAR
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA AND NAGAR HAVELI
DAMAN AND DIU
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU AND KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHADWEEP
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
NEW DELHI
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTAR PRADESH
UTTARAKHAND
WEST BENGAL
Pin Code
Landline No
Mobile No
Street Address
Permanent Address
State
SELECT -----
ANDAMAN AND NICOBAR
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA AND NAGAR HAVELI
DAMAN AND DIU
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU AND KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHADWEEP
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
NEW DELHI
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTAR PRADESH
UTTARAKHAND
WEST BENGAL
Pin Code
Landline No
Mobile No
Street Address
Local Address (Compulsory for students residing outside Bihar)
Qualification
Qualifying Exam
Last Exam Passed
Last School/College
Last Board/University
Last School/College Reg. No
School/College Name
State
City
% of Marks
Division
Pass Year
Board
+ Add More
*
*
*
*
*
*
Details of NEET (National Eligibility Cum Enterance Test)
Centre From Where Appear
Admit Card/Roll No.
Total Marks Obtained
Percentage/Percentile
Year in which NEET Given
Result of NEET Exam