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8th Floor, New Excelsior Building,Mumbai–400051.(M.S.).
Printable Application Form for Admission to Direct Second Year of Four
Year Degree Courses in Engineering & Technology for the year 2018-2019
Mode of Application : Diploma Application ID : DSE18100731 Version : 3
Personal Details
Gender Male Date of Birth 14-11-1997
Caste-Category (Sr.No.) OPEN Religion Hindu
Mother Tongue Hindi Family Income ( ) 3,50,001 - 4,00,000
Nationality Indian PWD Type N.A.
Maharashtra State
Type of Candidature Orphan No
Candidate - Type A
Religious Minority / Linguistic
N.A. Applied For TFWS No
Defence Type N.A.
I, the holder of Aadhaar Number [273335261119 ], hereby give my consent to State CET Cell to obtain my
Aadhaar Number
Aadhaar number for authentication with UIDAI. State CET Cell has informed me that my identity information
would only be used for admission purpose and will be submitted to CIDR only for the purpose of authentication.
District from which candidate has passed S.S.C.(Std. X)/Equivalent Examination Thane
District from which candidate has Passed Diploma Thane
Diploma Details
Diploma Status Passed Enrollment No 166430175
Course Electrical Engineering
Institute Type MSBTE Affiliated
Institute Name Shree Shankar Narayan Education Trust,Pravin Patil College of Diploma Engg. & Technology, Thane
English Medium Yes Pattern : Semester Diploma Roll/Seat No. 187682
Qualification Details
Examination Marks Obtained Marks Out Of Percentage
Diploma Final Year/Semester 955 1650 57.88
10th/S.S.C. Aggregate 327 500 65.40
10th/S.S.C. Mathematics 78 100 78.00
10th/S.S.C. Science 72 100 72.00
10th/S.S.C. English 61 100 61.00
12th/H.S.C. Aggregate 320 650 49.23
12th/H.S.C. Biology 42 100 42.00
Payment Details
Payment Date : 06-07-2018 Amount( ) : 800 /-
Note : Candidate shall carry printed copy of Application Form, Original documents and one set of Xerox copies of the required
documents. FC shall verify all documents from Original and put FC stamp with date & Signature on Xerox copies and return
original and verified documents along with Receipt-cum-Acknowledgement of application form. (Candidate shall submit FC
stamped & verified set of documents to ARC for re-verification after the allotment and then to the Institute at the time of
Note: List of Documents Required at the time of Document Verification and Confirmation at Facilitation Center (Do not attach
Xerox Copies)
List of Documents Required at the time of verification at FC.
1 Domicile Certificate of Candidate indicating that he/she is Domiciled in the State of Maharashtra
2 The School Leaving Certificate indicating the Nationality of the Candidate as 'Indian' Or The Place Of Birth In India.
3 Statement of marks obtained at 12th/HSC or its Equivalent Examination.
4 Statement of marks obtained at 10th/SSC or its Equivalent Examination
5 Statement of marks obtained at the Diploma Examination for each attempt in Final Year/Semesters.

Declaration:    I have read all the rules of admission and on understanding these Rules, I have filled this Application Form for
consideration of submission of Application Form at FC for the admission to Direct Second Year of Four Year Degree Courses in
Engineering & Technology for the academic Year 2018 - 2019. The information given by me in this application is true to the best of my
knowledge & belief. If at later stage, it is found that I have furnished wrong information and/or submitted false certificate(s), I am
aware that my admission stands cancelled and fees paid by me will be forfeited. Further I will be subject to legal and/or penal action as
per the provisions of the law.
Date : 25-07-2018 Place :   Signature of the Candidate
Last modified by : DSE18100731 Printed By : DSE18100731 (ABHINAV PRAJAPATI)
Last modified on : 06-07-2018 08:23:59 Printed On : 25-07-2018 01:15:27
Note: The Candidates are required to produce the documents in original for verification and Confirmation of Application Form at
FC. It is mandatory on the Candidates part to produce all original documents in support of the claim made by the Candidate in the
application form. Candidates are advised to keep the necessary documents ready at the time of Documents verification stage as
per the notified schedule.All FCs shall remain open on all days including holidays and Sundays during the schedule between 10.30
A.M. to 5.30 P.M.