Application Form

Printed on

8/31/2012 11:36:59 AM

Course

Bachelor of Engineering

Free Ship , 2012-2013

Special Backward Class

Application Number

APPe0362054M20092012

Appilcation type

Renewal

Please Paste
Passport Size
Photograph

Renewal Course Year 2011

Student SSC Details

SSC Board

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION

Passing Year

2009

SSC Seat No

e036205

SSC Marks Obtained

89.00

Applicant's Details
Applicant Name RASIKA

DATTARAM

Date of Birth

Gender

15-03-1994

Application Date 01-08-2012

Caste

Mother's Name

MHETRE

Is Resident of Maharashtra Maharashtra

Female

Maritial Status

No

Caste Category

Koshti (3-1)

Orphan

Sub Caste

No

SULABHA

Special Backward Class

N.A

Is Disabled

No

Disability Type

Is Applicant Salaried ? No

Applicant's
Annual Income

0.00

Total Annual Income 171479.00

Is Staying at Hostel ?

Has Applied For Hostel ?

No

N.A.

No

Student Prequalifying Details

Academic Year

Institute

Course

Course Year

Percentage

Result

2011 - 12

MGM's College of Engineering Bachelor of Biotechnology

& Technology, Kamothe.

35.00

Fail

2010 - 11

K.V.Pendharkar college of
arts,science and commerce .
Dombivli

12th Information Technology

63.00

Pass

2009 - 10

K.V.Pendharkar college of
arts,science and commerce .
Dombivli

11 th Information Technology

72.00

Pass

Institution Details
Name of School/College/Institute
where Admitted
Course Name

MGM's College of Engineering & Technology, Kamothe.

Bachelor of Engineering

CAP Number

EN1143622

Subject

Academic Year

2012-2013

Is Admission after Diploma No

College Adm.No 111BT1418

Admission Dt.

09-08-2011

Joining Date

Is Fees Paid ?

Yes

Fee Paid

1182.00

Fee Receipt No.

Fee Receipt
Date

01-082012

Course Year 2

GrantTyp Non
e
Granted

Quota

01-08-2012
c5/c/45812

Government Quota

Contact Details
Residential Number: 02512-440345, MobileNumber: 8652420743, EmailAddress: rasika150394@gmail.com

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Address For Correspondence

Address:- BLOCK NO.1 TLK N 66 "JAI SARASWATI SOC." OPP.VIRAT APT. TILAKNAGAR DOMBIVLI (E)
Location:- CITY City:- DOMBIVLI Pincode:- 421201 Taluka:- Kalyan District:- Thane
Parent / Guardian Details
Parent's name

DATTARA
M
Relation with Applicant Father
Parmanent Address
Is Father Alive

KISAN

MHETRE

Age

54(yrs)

Profession

Businessman

BLOCK NO.1,TLK N 66,"JAI SARASWATI SOC.",OPP.VIRAT APT.,

TILAKNAGAR,DOMBIVLI (E)
Annual Income 171479.00
Yes

Hostel Information
Name of Landlord /
Hostel

Hostel Admission
Date

Hostel Type

Is Mess Service Available?

Hostel/ Landlord
Address

No

Rent Per Month

N.A

Hostel/Landlord
Contact Details

Is Studying in night school

No

Document Details
Caste Certificate No

625/04

District Issuing Thane

Office

Taluka Issuing
Office

Thane

Caste Validity
Certificate No

146665

District Issuing Thane

Office

Scrutiny
Committee No

University
Registration No

111BT1418

Income Certificate
21121222818
No
Student Bank Account Details
Bank Name

BANK OF INDIA

Branch Name

KAMOTHE

IFSC Code

BKID0000142

Issued in

2012

Bank
Account No

014210110002959

MICR Code

400013142

Document Attached
Caste Certificate Issued by Competant Officer
Income Proof - Income Certificate Issued by Competant Authority
Marksheets
I-card Size Photo
Caste Validity Certificate
Non Creamy Layer Certificate
SSC Mark Sheet
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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