APPLICATION ID : RM7804 VALID PRINT
Office of the Chairman,
NEET UG Medical & Dental Admission/Counseling Board-2025
SMS Medical College, JLN Marg Jaipur
NEET UG (MEDICAL / DENTAL) COUNSELING 2025 (MBBS, BDS) (State of Rajasthan)
APPLICATION FORM
Course applied for : MBBS Category : OBC NCL
Opted for NRI seats : NO
Application ID : RM7804 NEET 2025 roll no. : 3923113239 Affix photo (as was
NEET 2025 score : 551 uploaded at the time
of filling on-line
Payment Type : APP. Reciept No. : 11000289746360 Amount Rs. : 2500 application form)
Name : NISHA JAT
Date of birth : 22-09-2007
Gender : FEMALE
Father's Name : SURESH CHAND JAT
Mother's Name : BARFO DEVI
Present address : CISF 8TH RESERVE BATTALION KUNDA, AMER, AMER - 302028, JAIPUR,
RAJASTHAN
Permanent address : DHANI HARNATH WALI MANDHA, KOTPUTLI - 303110, JAIPUR, RAJASTHAN
Residence phone : - Cell no. : 8688016211
email ID :
[email protected] Birth State : RAJASTHAN
Domicile State : RAJASTHAN
Nationality : INDIAN
Category : OBC NCL
PwD : NO
WDP / WPP : WPP WPP TYPE : WPP3
Has any member of your family taken benefit of this scheme in admission to a course anywhere in India : NO
Aadhaar/Enrollment No. : 91********28
OTHER ELIGIBILITY CRITERIA
I. Natural father/Mother of the candidate has continuously resided in Rajasthan for period of last 10 years and the
candidate has studied for at least 5 years during this period in a recognized educational institution in Rajasthan
Educational details
Secondary (10th ) or an equivalent examination
Name of board : CENTRAL BOARD OF SECONDARY EDUCATION
Year of passing : 2022 Percentage of total marks : 89.00%
10 + 2 or an equivalent examination
Name of board : CENTRAL BOARD OF SECONDARY EDUCATION
Result status : PASSED Year of passing : 2024 No. of attempts : 1
Percentage of marks in Physics : 88.00%, Chemistry : 75.00%, Biology : 89.00%, English : 93.00%
Total percentage of Physics, Chemistry, Biology : 84.00 %
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APPLICATION ID : RM7804
Bank Account Details
Bank Name : State Bank of India
Branch City : PAOTA
Branch IFSC : SBIN0031851
Branch MICR : 303002039
Account holder Name : SURESH CHAND JAT
Account No. : 20166696780
Declaration :
I do hereby declare that all the information given by me in support of my application for registration is true, complete and
correct to the best of my knowledge, is binding on me and nothing has been hidden by me. I shall not claim any change or
alteration. If any of them is found to be incorrect or false, my candidature will be liable to be rejected and I shall be liable
to any penal action and / or punishment as may be deemed fit by the UG admission board.
I have gone through all the rules, information booklet, instructions for filling on-line registration form college information
sheet, notification(s), fee structure etc. and I promise to abide by them.
I fulfill the prescribed eligibility criteria relating to educational qualification etc. for the course(s) I am applying for.
I hereby agree, if admitted, to abide by the rules and regulations in force at the college or those that may hereafter be made
for administration of the college and I undertake that so long as I am a student of the college, I will do nothing either inside
or outside the college that will interfere with its orderly working and discipline.
Applicant's signature (in box)
Left thumb Right thumb
Place : NISHA JAT
Date : RM7804
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APPLICATION ID : RM7804
Enclosures (as applicable):
1.NEET 2025 Score Card
2.Allotment Letter
3.Mark sheet(s) of 10+2 (senior school certificate examination) or its equivalent bearing Biology as one of the subjects (if
passed in more than one attempt, all mark sheets are required)
4.Date of Birth Certificate: 10th class mark sheet / certificate or any other equivalent showing the date of birth
5.Mark sheet of secondary examination (10th class)
6.Mark sheets of Class 11 bearing Biology as one of the subjects (if passed in more than one attempt, all mark sheets are
required)
7.Certificate/ Document providing your eligibility as selected by you at the time of filling on-line application form- (I to XI) -
as given under serial 3 under other eligibility criteria in the information booklet
8.Copy of photo ID (driving license / PAN card / Voter ID / Govt. or PSU card / School ID card / 12th class examination
admit card / Aadhaar card)
9.Valid Caste certificate, sub-category certificate, if applicable
10.Domicile certificate, if applicable
11.4 Passport size photo same as affixed on application form
12.Valid PwD certificate issued by 16 centers designated by MCC for NEET 2025, if applicable
13.Valid WDP / WPP certificates, if applicable
14.Valid EWS certificate, if applicable
15.Bond / Bank Guarantee as per the applicable Proforma
Additional documents for candidates applying for NRI seats:
16.If the Sponsor NRI/OCI/PIO is currently residing in India, a proof in the form of certificate issued by the Indian
embassy in the concerned Country/Ministry of external affairs, Government of India for this purpose is essential along
with undertaking in the prescribed Proforma-3 on non-judicial stamp paper of Rs. 50/- executed by Sponsor NRI/OCI/PIO
and duly notarized.
or
If the Sponsor NRI/OCI/PIO is residing outside India, a duly notarized undertaking in the prescribed Proforma-4 executed
by the sponsor and notarized by the Notary Public of the foreign country where the sponsor resides being submitted by
the sponsor, it be treated as sufficient as to the factum of the residence of the sponsor. NRI undertaking must have been
issued on or after date of NEET 2025 examination i.e. 04.05.2025.
17.Father/Mother/Guardian shall also submit an undertaking regarding relationship between Sponsor and candidate in
Proforma-5 along with the address of parents and local (Indian) guardian.
18.Address proof of parents and local (Indian) guardian.
Name : NISHA JAT
Registration ID : RM7804
Date and time of locking : 02-08-2025 20:00
Date and time of printing : 16-08-2025 23:37
NOTE:
Keep the completed application form for submission when required. You are not required to send to
UG admission board the print copy of your application form filled on-line. You will be required to
submit this printcopy of the application form (duly completed in all respects) at the time of reporting
before the admission board / allotted college.
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