Application Form

Please Paste Pasport Size Photograph

Application Number Appilcation type

Student SSC Details

APPL0095038M20022011 Renewal Renewal Course Year 2009

SSC Board Passing Year

Applicant's Details

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2002 SSC Seat No L009503 SSC Marks Obtained 74.00

Applicant Name Date of Birth

SHRINIVAS
first name

WAMANRAO
middle name

POTADAR
last name

Mother's Name Is Resident of Maharashtra Application Date

SUSHILABAI Maharashtra

07-06-1986

Gender

Male

Academic Year Caste Category Caste Orphan Is Applicant Salaried ? Maritial Status

2011-2012 Other Backward Class Sonar (154) No No Is Disabled Applicant's Annual Income Is Staying at Hostel ? Sub Caste No 0.00

20-10-2011

Disability Type

N.A. 40000.00

Total Annual Income Has Applied For Hostel ?

No

No

No

Student Prequalifying Details

Last attended School/College/Institute Last Exam Passed Passed

Institution Details

MBES COE Ambajogai Last Exam Passed Year 2011 Last Exam Marks 0

T. Y. (Mech) Yes

Name of School/College/Institute where Admitted Course Name Subject College Admission Number Is Fees Paid ? Fee Receipt Date 4125

M.B.E.Society's College of Engg,Ambajogai,Beed

Bachelor of Engineering (Mechanical) Is Admission after Diploma Date Of Admission Fee Paid Course Year Yes 25-07-2011 Academic Year Joining Date 2011-2012 25-07-2011

No

0.00 4

Fee Receipt No. Quota Government Quota

Contact Details

Residential Number: N.A, MobileNumber: 9975572878, EmailAddress: N.A

Address For Correspondence

Address:- c/o Potdar Waman M. District:- Latur

Location:- latur

City:- Nandgaon(sai)

Pincode:- 413512

Taluka:- Latur

Parent / Guardian Details

Parent's name

WAMANRAO
first name

MANOHAR
middle name

POTADAR
last name

Relation with Applicant Parmanent Address

Father

Parent Age

65

(yrs)

Profession

Labor

C/O POTDAR WAMAN MANOHAR AT. PO. NANDGAON, TQ. & DT.- LATUR

Parents Annual Income

40000.00

Hostel Information

Name of Landlord / Hostel Hostel Type

N.A

Hostel Admission Date Is Mess Service Available? No Rent Per Month

N.A

N.A

N.A

Hostel/ Landlord Address

N.A

Hostel/Landlord Contact Details

N.A

Is Studying in night school

Document Details

No

Caste Certificate No Caste Validity Certificate No Income Certificate No University Registration No

No.2004/MISC/WS/ 5231

District Issuing Office District Issuing Office

Latur

Taluka Issuing Office Scrutiny Committee No

Latur

12041

Issued in

2011

2009015200706286

Student Bank Account Details

Bank Name Branch Name

STATE BANK OF HYDERABAD AMBAJOGAI

Bank Account No

62134624743

Document Attached

Caste Certificate Issued by Competant Officer Income Proof - Income Certificate Issued by Competant Authority Marksheets I-card Size Photo

Declaration

The information furnished by me is complete and correct. I bear the complete responsibility for all the above information.

Applicant's Signature

Applicant Parent's Signature

Principal's Signature