Admission Form

.' I . rEr
ry *;rTrE!|,T!-rlr
College Code
:
Admissiondate: t
For college
use
Course Admitted to
only -
I Division
I
Form No.
lRollNo.
:
llr
Please paste a
passport size (35 mm
x 45 mm) Photograph
Kindly read important notes before filling - in form :
l. Use black ink to fill in the form and Do NOT overwrite.
2. Fill in all fields in CAPITAL letters only.
3. strike-off whichever is Nor applicable.E.g.lf you are a Male:-Gender:Male/Female
Course applied for (e.g. BA / BCom / BE)
Course Part or semester applied for (e.g.
here, Do NOT staple.
Photo should not
exceed the borders.
A
:
fI
Pur 1l2l3l4
I Student should sion strict
inside this box
black ink
Applying for Conession EBC / SC / ST / NT I oBC lsBC / PTC/ STC / Freedom rigGiTEx-Se.riceMn
l.
onlwith
,
Personal Information Section
Last Name
Name of the Student
First Name
Middle Name
:
(ln case of changed name, write current name)
Name of the Student :(In Devnasari scrint)
Nam_e of the Stud€nt as prinled on std. 10 passing
certificate
Father/ Husband's Name
Mother's Name
:
:
Previous name of the student
:
(ln case of changed name)
Reason for name changed : Willingly / After Marriage
Date of Birth (DD/MM/YYYY) :
Place of Birth :
Religion
/
I
Blood Group (with Rh)
Citizen of (country name)
:
Address for Correspondence
State :
Marital status : unmarried / Married / Divorced / widowed / Deserted
Gender: Male I Female
I District:
Tehsil
City/Town/Village
Address (House no, Stroevarea etc.)
Permanent Address (write only if different than 'Address for correspondence,)
State:
I Oistrict:
Tehsil :
Address (House no, StreeUarea etc.)
Gity/TownA/illage
PIN Code:
Contact Details
Phone
#I
Area / STD Code
Mobile Number
:
lplrone No.
Phone#2:
:
PIN Code:
lareatSTDCode:
:
|.
lphoneNo.
Email lD
:
2. Legal Reservatlon Inforrnation Section
: I Category : Open / Reserved
I Sub-Caste:
Res€rvation Information Section (check (V)
Domicile of State
Caste:
3. Social
Ex-Serviceman/Ward of Ex-Serviceman
Active-Serviceman/Ward of Active-serviceman
Freedom Fighter/Ward of Freedom Fighter
Ward of Primdry Teacher
Ward of Secondary Teacher
Deserted/Divorced/Widowed Women
f Reserved : SC / ST / DT(A) / NT(B) / NT(C) / NT(D) / OBC / SBC
5[R$L?,':'r:,:"115J]?oil"YH,il'E:lf.e[E'Ee*;h-;^' """'"g tmp;ireai
Whichever is applicable, write name of supportins document attached- ;r*-ffi7
Member of Project Affected Family
Member of Earlhquake Affected Family
Member of Flood / Famine Affected Family
Resident of Tribal Area
Kashmir Migrant
4. sclccted/optedPapers Section (write paper codes or paper name, in tne boxes)
Year / Semester : 1l3l5l7
Semester : Z41618 (if decided in First Semester only)
1.
2.
3.
4.
5
2
3
4.
5
g
6.
7.
8.
9.
8.
9.
7.
urn Over
fE
.lr!'.rryry1w
r-
l.r!ryt7lrTt
.twr-'
tnt.vr.trr..wr!
r.
5. Educational Details Section (Write'YES' in last column, against qualifying examination, on basis of which you are seeking admission to the said
course write NO in front of other examinations) Please Note : 1Oth details are mandatory in any case.
Name of
Examina
tion
std
std
Name of Board
/ University
Date of
Passing
(DD/MM/
YYYY)
Name of School
/ College
I
Degree/
Passing
Certificate
Examinati
on Seat
No. (Last)
No.
Grade/
Total
Qualifying
Examination
(YES/NO)
Out
of
Marks
Obtained
10 th
12
rh
6. Guardialtrs Inforrnatiorr Scctiorr
Guardian's Name
:
Occupation of the Gurdian: Service/Business/ Profession I Farme( / Laborer/ Retired lAnnual lncomeof theGuardian (RsJ
(Last
Relationship of Guardian with applicant
Financial Year)
|
Phone No.
:
7. Altached Documents and Certificates Section
Sr. No
Name of Documenl / Certificate
Original /Attested True Copy
Passing Certificate of Std 10 th
Attached True Copy
/
of Std
2.
Passing Certificate of Std 12
3.
Leeaving Certificate
4.
Cert,ficate of Caste with Category
Atlached True Copy
5.
Non Creamy Layer Certificate
Atlached True Copy
6.
Affidavit for changed name / Marriage Certificate i Govt. Gazette
7.
Domicile Certificate
Attached True Copy
8.
Certificate for Physically Challenged
Attached True Copy
th
Statemenl of Marks
12 th
Attached (YES / NO)
Attached True Copy
Original
L
10
11
12.
ll. Othcr infornralion
Mother Tonque
Sc.clion
Employment status : Employed /
:
Unemployeo I
oo you wish to join Ncc/NSS
:
yES / No
Would you like to apply for Hostel : YES / NO
Hobbies, Proficiency and Other lnterests
Ganres
Lcvcl
:
&
SJxrrts Parricipation :
(c.9. college / state / national
/
international etc. )
:
9. Dcclaration by Studcut
I hereby declare that, I have read the rules related to admission and the information filled in by me in this form is
oIl[r-
acerrale and true ro,n"
will be responsible for any discrepancy, aarising out of the form signed by me arrd I undertake that, in absence of any document the
final
admission will not be granted and / or admission will stand cancel.
knowledge.
I
I
am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that I will abide by all the rules and regulations of the
said Act.
Place
:
Date:
Sinnrtrr" of th" S,r.un,
'
10. Dcclaration by Guardian
I have permitted my son / daughter / ward to join your college. The information supplied by him
/ her is correct to the best of my knowledge.
i have acquainted myself with the rules and fees, dues to my son / daughter / ward and to see that he / she observes.
Place :
Date:
ll. For College / Institute
Signature
of
the Guardian
:
Use Only
Designation
Remarks / Particulars / Recommendations
Signature and Date
Admission Clerk
Admission Committee
Account / Cashier
Registrar / Office Superntendent
Principal / Director
Cash Received Rs.
:
Receipt No.
: