ONLINE APPLICATION REGISTRATION FOR DENTAL MECHANIC 2025
USER ID MRBDMW25000317
POST APPLYING FOR DENTAL MECHANIC
PERSONAL DETAILS
NAME GOWTHAM R
NATIONALITY INDIAN
GENDER MALE
ARE YOU APPLYING UNDER THE EX-SERVICEMEN NO
CATEGORY?
DO YOU HAVE COMMUNITY CERTIFICATE ISSUED YES
BY TAMIL NADU GOVERNMENT?
COMMUNITY MBC/DNC
SUB CASTE AMBALAKARAR
ISSUING AUTHORITY OF COMMUNITY CERTIFICATE ZONAL DEPUTY TAHSILDAR
COMMUNITY CERTIFICATE NUMBER TN-5202407319678
COMMUNITY CERTIFICATE PLACE OF ISSUE VALAPADY
COMMUNITY CERTIFICATE ISSUING DATE 02-AUG-2024
ARE YOU DIFFERENTLY ABLED? NO
DATE OF BIRTH (AS PER SSLC MARK SHEET) 10-JUN-2001
AGE AS ON 01-07-2025 24 YEARS 0 MONTHS 21 DAYS
EMAIL ID GOLDENGOWTHAM106@[Link]
MOBILE NUMBER 9489760643
WOULD YOU LIKE TO GIVE FATHER AND MOTHER FATHER AND MOTHER
NAME OR GUARDIAN NAME
FATHER'S NAME RAJENDIRAN
MOTHER'S NAME MALA
ARE YOU MARRIED? YES
NAME OF SPOUSE PRIYANKA DEVI
NATIVITY SALEM - TAMIL NADU
RELIGION HINDU
ARE YOU ALREADY IN GOVERNMENT SERVICE? NO
PHOTO ID PROOF DETAILS
PHOTO ID PROOF VOTER ID
PHOTO ID PROOF NUMBER XRE2117877
PERMANENT ADDRESS
ADDRESS 1/389V, GANDHI NAGAR, VILAMPATTI,VALAPADY TK
STATE TAMIL NADU
DISTRICT SALEM
CITY / VILLAGE VALAPADY
PINCODE 636139
CORRESPONDENCE ADDRESS
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ADDRESS 1/389V, GANDHI NAGAR, VILAMPATTI,VALAPADY TK
STATE TAMIL NADU
DISTRICT SALEM
CITY / VILLAGE VALAPADY
PINCODE 636139
MOTHER TONGUE TAMIL
WHETHER ANY CRIMINAL CASE HAVE BEEN FILED NO
AGAINST YOU?
EDUCATIONAL QUALIFICATION
ELIGIBLE QUALIFICATION
HAVE YOU PASSED THE EDUCATIONAL QUALIFICATION FOR THE POST OF DENTAL MECHANIC BEFORE THE PUBLICATION OF DENTAL
COUNCIL OF INDIA REGULATIONS, 2008:
NO
EXAMI NAME OF SPECIAL PERIOD DURAT NAME OF MONTH DO TOTAL TOTAL PERC MEDI CERTIFI HAVE
NATIO BOARD / IZATION OF STUDY ION INSTITUT & YEAR YOU MAXIMU OBTAINE ENTAG UM CATE YOU
N DIPLOMA FROM - TO OF ION OF HAVE M D E OF OF ISSUED STUDI
NAME / STUDY PASSIN MARKS MARKS MARKS MARK INST DATE ED
CERTIFICA G FOR S RUCT TAMIL
TE (NUMB THE ION AS
COURSE ER OF DIPLOM ONE
NAME YEARS A/ OF
) CERTIF THE
ICATE LANG
COURSE UAGE
? (PART
-1)
10TH / TAMIL - --- - - MAY - 500 370 74.00 TAMIL 25- YES
SSLC NADU 2016 MAY-20
STATE 16
BOARD
12TH / TAMIL PHYSICS - - - - - MAY - 1200 622 51.83 TAMIL 16- YES
HSC NADU , 2018 MAY-20
STATE CHEMIS 18
BOARD TRY
AND
BIOLOG
Y
DIPLO DIPLOMA - 2018 - 3 VINAYAKA JANUAR YES 900 538 59.78 ENGL 17- NO
MA IN 2021 MISSIONS Y 2021 ISH APR-202
DENTAL SANKARAC 1
MECHANI HARIYAR
C DENTAL
COLLEGE
SALEM
EXAMINATION ARE YOU A REGISTERED DATE OF REGISTRATION DENTAL COUNCIL REGISTRATION REGISTRATI
DENTAL MECHANIC WITHIN REGISTRATION CARD TYPE ON VALID
THE TAMIL NADU STATE NUMBER UPTO
DENTAL COUNCIL
REGISTERED IN YES 24-SEP-2021 1138 RENEWAL CARD 31-
TAMIL NADU DEC-2026
STATE DENTAL
COUNCIL
ARE YOU ELIGIBLE TO AVAIL PSTM PREFERENCE? NO
OTHER QUALIFICATION
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DO YOU HAVE ANY OTHER QUALIFICATION? NO
UPLOAD DOCUMENTS
DOCUMENT NAME FILE NAME
COMMUNITY CERTIFICATE [Link]
SSLC CERTIFICATE [Link]
HSC CERTIFICATE [Link]
DIPLOMA CERTIFICATE [Link]
DIPLOMA CERTIFICATE MARKSHEET [Link]
DENTAL COUNCIL REGISTRATION CERTIFICATE [Link]
DECLARATION
I HEREBY DECLARE THAT ALL THE PARTICULARS FURNISHED IN THIS APPLICATION ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF
MY KNOWLEDGE AND BELIEVE. IN THE EVENT OF ANY INFORMATION BEING FOUND FALSE OR INCORRECT OR INELIGIBILITY BEING DETECTED
BEFORE OR AFTER THE SELECTION, ACTION CAN BE TAKEN AGAINST ME BY THE MRB.
I HEREBY DECLARE THAT I WILL NOT BE A PARTY TO ANY KIND OF CANVASSING ON MY BEHALF.
I FURTHER DECLARE THAT I FULFIL ALL THE ELIGIBILITY CONDITIONS PRESCRIBED FOR ADMISSION TO THIS POST.
I HAVE INFORMED MY EMPLOYER IN WRITING THAT I AM APPLYING FOR THIS POST AND FURNISH THE NOC FOR THIS PURPOSE (IF
APPLICABLE).
I HAVE GONE THROUGH THE INSTRUCTIONS ETC. TO CANDIDATES AND THE BOARD'S NOTIFICATION FOR THIS RECRUITMENT, BEFORE
FILLING UP THE APPLICATION FORM AND I AM ELIGIBLE TO APPLY FOR THIS POST.
I DECLARE THAT I POSSESS THE MEDICAL STANDARDS PRESCRIBED FOR THE POST(S) WHICH I AM NOW APPLYING.
I CERTIFY THAT I HAVE NOT BEEN DEBARRED / DISQUALIFIED BY THE BOARD OR ANY OTHER RECRUITING AGENCY.
I AM NOT A DISMISSED GOVERNMENT EMPLOYEE.
THERE IS NO CRIMINAL CASE FILED AGAINST ME IN THE POLICE STATION / COURT.
THERE IS NO VIGILANCE CASE FILED AGAINST ME.
I HEREBY DECLARE THAT MY CHARACTER / ANTECEDENTS ARE SUITABLE FOR APPOINTMENT TO THIS POST.
I DECLARE THAT I DO NOT HAVE MORE THAN ONE LIVING SPOUSE / I AM UNMARRIED.
I ACCEPT THAT IF ANY SUPPRESSION / INCORRECT / FALSE / MISLEADING INFORMATION SUBMITTED IN THE ONLINE APPLICATION WILL
RESULT IN THE REJECTION OF MY CANDIDATURE WITHOUT FURTHER NOTICE.
☑ I ACCEPT THE ABOVE DECLARATION.
SUBMITTED DATE : 07-JAN-2026 (SIGNATURE OF THE CANDIDATE)
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