THE BOARD OF CONTROL FOR CRICKET IN INDIA

BCCI AVP PLAYER REGISTRATION FORM (U16) 2014-2015

Points to note:

1.Adherance to BCCI Age Verification Programme is compulsory for participating in U

2.Cut-off date for U-16: Born on or after 1-9-1998 are eligible for BCCI AVP screening
3.Scanned copy of Original Birth Certificate is mandatory with every form.
4.Form to be filled in electronically in CAPITAL Letters.
Name of the Association:

MUMBAI CRICKET ASSOCIATION

SECTION 1: CHRONOLOGICAL AGE (Personal details to be filled in by the Parent/Team Officials)

Full Name of Player:

VARUN

SHRINIWAS
(First Name)

Date of Birth: (DD/MM/YYYY)

Residential Address:
Phone No.:

(24/10/1999)

402, ADITI SOCIETY, SENA BHAVAN LANE, NC KELKAR ROAD, DADAR. MUMBAI 40

022-24222277

Place of Birth: Village

(Middle Name)

Mobile No.:

MUMBAI

9892408586
District

MUMBAI

Name of Hospital (where born):

Birth Certificate

Date of Issue 31/12/1999

Serial No.

School Certificate

Date of Issue

Serial No.

SCA Player Registration

Date of Issue 31/12/2012

Serial No.

Passport

Serial No.

Date of Issue

Father's Name:

SHRINIWAS SURENDRA JOIJODE

Mother's Name:

SHARMILA SHRINIWAS JOIJODE

Parents Date of Marriage

19/12/1997

Fathers Mobile No.:

9892408586

000065770/8363
M23248

Date of Expiry

Fathers Email:

Brothers/Sisters:
Sr. No
1

Name

Male/Female
Male

RUDRA SHRINIWAS JOIJODE

2
3
4
5
*Step brothers/Step sisters not to be included
Height: (cms) 155

Weight (Kgs)

SECTION 2 DENTAL AGE: (To be filled with the help of family Doctor/SCA Physiotherapist)
3rd Molar Erupted

(Yes / No)

YES

Space behind 3 Molar (>15 years)

(Yes / No)

NO

Doctor/Physio's Name:

Signature

rd

DR RONAK U HOSABETTU

Declaration: Parent
We hereby accept the BCCI Age Verification Protocol and give our consent for the player to undergo one (01) x-ray
the above protocol have been explained to me. We have also read the BCCI AVP Information for Player/Parent.
Signature: Parent :
Declaration: SCA

Certified that Mr. _________________________________________whose photograph is given above has been x-rayed by the
undersigned & I certify that x-ray belongs to the player whose photograph is pasted above and information given is

Signature: SCA AVP Officer

SECTION 3 BONE AGE:

Radiologist Name
TW3 RUS

(FOR USE BY BCCI AVP Dept. ONLY)

Bone Age/BCCI
Bone Age/BCCI
Bone Age/BCCI
Radiologist 1
Radiologist 2
Radiologist 3

TW3 Carpals
Bonexpert
MRI
Misc.
Remarks:
Signature BCCI AVP Dept.:
This is an electronically signed document. Does not need a signature

Name

CKET IN INDIA
Recent
Electronic
Photo

M (U16) 2014-2015

or participating in Under-16.

BCCI AVP screening.

ery form.

am Officials)
JOIJODE

ame)

(Last Name)

, DADAR. MUMBAI 400028

Email:

varun.joijode@yahoo.com

State

MAHARASHTRA Country

770/8363

INDIA

Issuing Authority:MUNICIPAL CORPORATI

Issuing Authority:
Issuing Authority:MCA
Issuing Authority:

Date of Birth

22/6/1969

Date of Birth

25/1/1973

sriniwas.origin@gmail.com

Male/Female

Date of Birth

Male

22/8/2005

(Kgs)

37.3

apist)

Reg.No.

L-22545

ndergo one (01) x-ray of the wrist and hand. The details of
for Player/Parent.
Date

22/10/2014

as been x-rayed by the Association in the presence of

nd information given is correct.

Signature: Hony. Secretary

ne Age/BCCI
adiologist 3

Eligibility Remarks

Date