Application Form

Printed on Course 8/27/2012 6:35:40 PM Bachelor of Management Studies GOI Post Matric Scholarship , 2012-2013 Scheduled Caste

Student Passed SSC Exam from Open Category . Please verify SSC marksheet.

Application Number Appilcation type Student SSC Details SSC Board Passing Year

APPOPE0522944M200820 12 Renewal

Renewal Course Year 2010

Please Paste Passport Size Photograph

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2008 SSC Seat No OPe052294 SSC Marks Obtained 53.69

Applicant's Details Applicant Name VIJAY Date of Birth 16-09-1992 LAXMAN Gender Male No GAJAKOSH Mother's Name MEERA

Is Resident of Maharashtra Maharashtra Caste Category Sub Caste Scheduled Caste

Application Date 20-08-2012 Caste Orphan Dhor (18) No

Maritial Status

Is Disabled Applicant's Annual Income

No 0.00

Disability Type

N.A.

Is Applicant Salaried ? No Is Staying at Hostel ? No

Total Annual Income 60000.00 No

Has Applied For Hostel ?

Student Prequalifying Details

Academic Year Institute Course Course Year Percentage Result

2011 - 12

R.K.TALREJA COLLEGE & Bachelor of Management CENTRE FOR MANAGEMENT Studies COURSES R.K.TALREJA COLLEGE & Bachelor of Management CENTRE FOR MANAGEMENT Studies COURSES S.D.T. KALANI COLLEGE 12 th (Commerce)

54.00

Pass

2010 - 11

53.00

Pass

2009 - 10

52.89

Pass

Institution Details Name of School/College/Institute where Admitted Course Name Subject College Adm.No 53543 Is Fees Paid ? Fee Receipt Date Contact Details Residential Number: , MobileNumber: 9766648936, EmailAddress: gajakoshvijay@yahoo.in Address For Correspondence Address:- kamla nehru nagar dhobighat opp annapurna kirana store near durga mata mandir Location:- ulhasnagar City:- ulhasnagar Pincode:- 421001 Taluka:- District:- Thane ulhasnagar 421001 1 Of 2 No N.A R.K.Talreja College of Arts, Science & Commerce CAP Number 2012-2013 15-06-2012 0.00 GrantTyp Non e Granted Is Admission after Diploma No Joining Date Fee Receipt No. Quota Government Quota 18-06-2012

Bachelor of Management Studies Academic Year Admission Dt. Fee Paid Course Year 3

Parent / Guardian Details Parent's name LAXMAN NARAYAN GAJAKOSH Age Profession 52(yrs) Labor

Relation with Applicant Father Parmanent Address Is Father Alive Hostel Information Name of Landlord / Hostel Hostel Type Hostel/ Landlord Address Is Studying in night school Document Details Caste Certificate No Caste Validity Certificate No 0711-1993 N.A District Issuing Thane Office District Issuing N.A Office Issued in 2012 No Is Mess Service Available? No

Kamla nehru nagar dhobighat opp annapurna kirana store near durga mata mandir ulhasnagar 421001 Annual Income 60000.00 Yes

Hostel Admission Date Rent Per Month Hostel/Landlord Contact Details N.A

Taluka Issuing Office Scrutiny Committee No University Registration No

Ulhasnagar N.A N.A

Income Certificate 4249/2012 No Student Bank Account Details Bank Name Branch Name IFSC Code UNION BANK OF INDIA ULHASNAGAR UBIN0532029

Bank Account No MICR Code

320702010115727

400026083

Document Attached Caste Certificate Issued by Competant Officer Income Proof - Income Certificate Issued by Competant Authority Marksheets Declaration The information furnished by me is complete and correct. I bear the complete responsibility for all the above information. Applicant's Signature Principal's Signature _______________________ _______________________ Applicant Parent's Signature _______________________

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