To, Form Number:MUM10303

The Divisional Secretary,

Maharashtra State Board of Secondary And Higher Secondary Education,
MUMBAI Divisional Board.
Sir,
I request you to issue enrolment Certificate as a Private Candidate at the S.S.C Examination(Std.X) to
be held in March 2018 and submit the following particulars for your information.

Full Name ANISH RAJESH BHAGYAWANT

Mother's Name ASHARANI
Residential Address Behind Munisipal Colony, School No.3,
C-22, Room No.5, R B Kadam Marg,
Bhatwadi, Ghatkopar W
Residential PinCode 400084
Residential District GREATER MUMBAI
Residential State MAHARASHTRA
Adhar Number 236902872372
Email ID of student classiscybercafe01@gmail.com
Mobile Number 8433779029
Birth Date 05/29/2002
Birth Date In Words May Twenty Ninth Two Thousand Two
Birth Village/Town Mumbai
Birth taluka Kurla
Birth District Mumbai
Gender Male
Medium English
Name of Last Attended School The North Bombay Welfare Societys
High School
village/town of Last Attended School Ghatkopar
Taluka of Last Attended School Kurla
District of Last Attended School Mumbai
State of Last Attended School Maharashtra
Pincode Of Last Attended School 400086
Udise Code 27230300436
Is handicap no
Date of leaving the last attended School 06/30/2017
Standard in which studying at the time of 9
leaving school
Pass/Fail/Studying failed
Debarred from appearing at any of the no
examination
 Undertaking to be given by the candidate

i) I,ANISH RAJESH BHAGYAWANT hereby declare that shall complete

the Practicals,in Science and Technology and Information Communication
Technology Subjects,Self Learning Material Prescribed by the Board and the
Prescribed course of studies for optional/school subject for std.X through the
contact center.If I fail to comply with the same,the decision of the Divisional
Board shall be binding on me.

ii) I am aware that I am not eligible to offer the technical subject.

iii) I am aware that in case any further enquiry (regarding my previous

schooling age,etc.) is found necessary by the authorities concerned and if the
enquiry is not completed in good time, I understand that I shall have to submit
a fresh application for the following examination.

iv) The above information has been filled in by me personally in may own
handwriting and it is as per the original documents produced by me along with
the Application form.I also hereby agree to abide by the Maharshtra Secondary
and Higher Secondary Education Boards Regulation 1977 and all the
instructions issued by the board.

v) I have not passed the SSC Examination,conducted by the Maharashtra State

Board of Secondary & Higher Secondary Education or any other equivalent or
higher examination of any statutory Board or University.

vi)I here by declare that I have not joined any recognised school since I left
the school mentioned at Sr.No.6

Place: GREATER MUMBAI Signature

Of Applicant
IP: 111.119.227.71
Date: 8/11/2017 (ANISH RAJESH BHAGYAWANT)

Note: Kindly submit application form to

MAHESHWARI VIDYALAYA, GHATKOPER, MUMBAI 84(3304055)

Along with original documents and processing fees Rs.1100 before 21st August 2017.
 RECEIPT(For Office Use)

EC NO:MUM10303 Date:8/11/2017

From, ANISH RAJESH BHAGYAWANT Received Rs.ELEVEN

HUNDRED only for the Enrollment & Processing as a private Candidate for
SSC Examination.

Cashier

RECEIPT(For College Use)

EC NO:MUM10303 Date:8/11/2017

From, ANISH RAJESH BHAGYAWANT Received Rs.ELEVEN

HUNDRED only for the Enrollment & Processing as a private Candidate for
SSC Examination.

Cashier

RECEIPT(For Student)

EC NO:MUM10303 Date:8/11/2017

From, ANISH RAJESH BHAGYAWANT Received Rs.ELEVEN

HUNDRED only for the Enrollment & Processing as a private Candidate for
SSC Examination.

Cashier