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Student's Information

Student's Information

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Published by Nilesh Nagose

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Published by: Nilesh Nagose on Oct 04, 2012
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05/13/2014

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ALL INDIA SHRI SHIVAJI MEMORIAL SOCIETY’S

COLLEGE OF ENGINEERING, PUNE –1
STUDENTS’ COUNSELLING CELL
STUDENT INFORMATION

Name of Student: ______________________________________________________________
Roll No: _____________________ Department / Branch: ________________________
Category: _________ Religion: ______________ Caste: __________________________
Gender [Male / Female]: _______ State of Domicile: __________ Mother Tongue: __________
Languages known: ______________________________________________________________
Date of Birth: __________ Blood Group: _______ Mobile No: _____________________
Landline No: __________________ E-mail id: ____________________________________
Local Address: ________________________________________________________________
_____________________________________________________________________________
Permanent Address: ____________________________________________________________
____________________________________________________________________________
Father’s Information:
Education: ______________ Occupation: ______________ Designation: _________________
Office Address: _________________________________________________________________
______________________________________________________________________________
E-mail id: __________________ Mobile No.: ____________ Landline No.: ________________
Mother’s Information:
Education: ___________ Occupation: _________________ Designation: _________________
Office Address: ________________________________________________________________
_____________________________________________________________________________
E-mail id: __________________ Mobile No.: ______________Landline No.: _______________
Name of local Guardian & address: ______________________________________________
_____________________________________________________________________________
E-mail id: ________________Mobile No.: ______________Landline No.: _______________

I hereby declare that the above information as it relates to me is true and correct. I shall be responsible
to inform to office for any in above information.

Signature of Student Signature of Parents
*Please tick mark the address for correspondence
Affix self
attested
passport
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