Chaudhary Charan Singh University, Meerut

Private Examination Form (Session-2009-10)

Roll No:Z112310149

112 Raguwar Dayal-Prabhu Dayal Kanya Mahavidyalaya, Jahangirabad (Bulandshahr)

Enrollment No. : 0308871

Name of Examination : M.A.-1

Name of Student : SANTOSH K.M Nationality : INDIAN Attested photograph by
Father`s Name : VED PAL SINGH Nationality : INDIAN The Principal or any
Mother`s Name : SUNITA DEVI Nationality : INDIAN Gazetted Officer
Date of Birth (y-m-d) : 1984-08-10 id:163496
Sex : Female Original Resident of : U.P. ..............................................
Caste : General Subcategory : None Medium of Examination : HINDI Intermediate stream : ART
Subject : HINDI, ,
Permanent Address Present Address Signature of candidate
VILLAGE. PALI ANAND GARHI, POST. RAGHUNATH VILLAGE. PALI ANAND GARHI, POST. RAGHUNATH
PUR BULANDSHAHR PUR BULANDSHAHR
BULAND SHAHR BULAND SHAHR
BULANDSHAHR, Pin : 245405 BULAND SHAHR, Pin : 245405
Main Subject :
1.Hindi Sahitya ka Itihas Evam Sahityak Nibandh 125
2.Gadhya Sahitya 126
3.Kavyashastra Evam Sahitya Lochan 127
4.Adhunik Kavya 128
5.Vishistha Rachnakar (Tulsidas) 226
6.
7.
8.
9.
Qualifying Course1 :
1.
Qualifying Course2 :
1.

Description of Examination:
Name of Examination Name of Board/University Roll Number Years Division Mrk obt Mrk max
High School U . P. BOARD 0525939 2000 2ND 323 600
Intermediate U . P. BOARD 087902 2002 2ND 229 500
Graduation CCS UNIVERSITY A0087057 2006 2ND 568 1200
Post Graduation 0 0
Other 0 0
Details of previous examination passed from C.C.S. University(if any)
CCS University, Meerut 0
If appearing in Part II & III Year Examination, give details of marks obtained in previous examination Result Marks

Year Result Obtained Maximum

Part I Roll No. Select Marks Obtained
Part II Roll No. Select Marks GT I + II
Part III Roll No. Select Marks GT I+II+III

Details of Punishment in Any Examination (if Any)

Name of Examination Punishment Details Roll No. Year Name of center

If Migration Certificate taken from University, If Yes give the No and Year

If you are employed give the details of No Objection Certificate

Page 1/3
Length of residence in U.P.

Year of Admission to Degree Class in the College

Whether doing Ph.D. or any other degree of any other University in India/Abroad, you may please state full particulars.

The Examination for which studying/appearing at the time of filling the form

If enclosed Migration Certificate of another University/Board mention its No.

Checklist (Attached Documents) Any other certificate

Marksheet of High School : No
Marksheet of Intermediate: No
Certificate of High School: No
Certificate of Intermediate: No
Migration Certificate: No
Bank Challan Form : No
Marksheet of Graduation -Ist year: No
Marksheet of Graduation -IIrd year :No
Marksheet of Graduation -IIIrd year : Yes
Minority Certificate : No
Marksheet of Post Graduation Ist year : No
Marksheet of Post Graduation IInd year : No
Domicile Certificate : No
Cast Certificate : No

Declaration
I SANTOSH K.M(Z112310149) hereby declare that the information given in the application form is true to the best of my knowledge and belief. In case

any information is found untrue, cancel my admission,for which no claim of refund of fee would be raised by me, In future also, if any particulars

submitted are found to be untrue, the university can cancel my Degree.

(Signature of the Applicant)

Certificate by the principal

Sri/Smt/Km. SANTOSH K.M(163496) son / daughter of Sri VED PAL SINGH has been registered for private examination. All the entries in the exam

form, marksheets and other certificates attached have been duly checked and this is certified that he/she is eligible for the examination and his/her

examination form is being forwarded.

Dated :

Signature of the checker Signature of the Principal with stamp

Page 2/3
Student Copy STATE BANK OF INDIA

Account No : 30990406022
Account Name : Chaudhary Charan Singh University, Meerut
Id/Ref No : Z112310149
Name of Student : SANTOSH K.M
Application No. : 163496
Course/Class : 01

Name of Examination : M.A.-1 (To be entered by Bank employee)

Fee Head Amount
Examination Fee 1500 Journal No. :
Registration Fee 65
Permission Fee 100 Receipt Date :
Total 1665 Signature of Bank Official:

----------------------------------------------------------------------------------------------------------------------------------------------------------------

University Copy STATE BANK OF INDIA

Account No : 30990406022
Account Name : Chaudhary Charan Singh University, Meerut
Id/Ref No : Z112310149
Name of Student : SANTOSH K.M
Application No. : 163496
Course/Class : 01

Name of Examination : M.A.-1 (To be entered by Bank employee)

Fee Head Amount
Examination Fee 1500 Journal No. :
Registration Fee 65
Permission Fee 100 Receipt Date :
Total 1665 Signature of Bank Official:

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Bank Copy STATE BANK OF INDIA

Account No : 30990406022
Account Name : Chaudhary Charan Singh University, Meerut
Id/Ref No : Z112310149
Name of Student : SANTOSH K.M
Application No. : 163496
Course/Class : 01

Name of Examination : M.A.-1 (To be entered by Bank employee)

Fee Head Amount
Examination Fee 1500 Journal No. :
Registration Fee 65
Permission Fee 100 Receipt Date :
Total 1665 Signature of Bank Official:

Page 3/3