STUDENT COPY

Faculty of Technology & Engineering (3386)

Application No :
The Maharaja Sayajirao University of Baroda 247373
Fatehgunj, Vadodara-390 002, Gujarat (India)
Academic Year: 2020-2021 Regular
ADMISSION FORM

Course Applied for : Bachelor of Engineering-Chemical Engineering-Regular-BE-IV-SSBE-IV  (619112) PRN:2017033800113881

Application Date : 17/03/2021 Payment Category : 55
Exam Center Name [Code] : - [-]
1.Personal Information
Candidate's Name(Regional) :
Candidate's Name as printed on GOJIYA HARISH BHIKHABHAI
School leaving/Passing Certificate [*This name will appear on all University
: records/documents]
Father's/Husband's Name : BHIKHABHAI GOJIYA Mother's Name : JANJIBEN
Marital Status : UnMarried Mother Tongue :
Place of Birth : DEVALIYA Gender : Male Date of Birth (DD/MM/YYYY) : 01/06/1998
Blood Group : Religion : Country of Citizenship : India
Weight : Not
Height : Not Available Hemoglobin : Not Available
Available
Is Student NRI/ Foreign National : No Domicile State: Gujarat
Address For Correspondence :
Tehsil/Taluka : Location Area : Not
State : Gujarat District : Jamnagar City/Town/Village :
Khambhalia Available
Address (House
no,street/area/suburb At. Devaliya vadi vistar Jamnagar , khambhaliya Pin Code : 360510
etc.) :
Contact details
Mobile Primary Email ID:
916355543614
Number harishgojiya2000@gmail.com
2.Legal Reservation Information
Category Type :
Category : SEBC
Reserved
Is Specially Abled? No Are you Employed/Self-employed?  NO
3.Social Information(Additional Information)

Paper Selected for:

SSBE-IV

CHL1801 - Modelling Simulation and Optimization
CHL1803 - Petroleum Refinery Engineering
CHL1804L - Process Synthesis and Economics-Tw/Viva
CHL1806 - Seminar-Termwork including Viva
CHL1801L - Modelling Simulation and Optimization-
Tw/Practical/Viva
CHL1804 - Process Synthesis and Economics
CHL1805 - Project-term Work Including Viva
CHL1807 - Petrochemical Technology

Medium of Instruction : English

Admission Fee Payment Fee Category : SEM ADM Fees - Regular - Boys -
Over All Payment Status: : Paid
Details [MSURP]
Admission Fees - 250 Laboratory/Field Work/Studio Fees - 0
Equipment Maintenance Fees - 0 Faculty/College/Institute Library Fees - 0
Management Training & Development Fees - 0 Miscellaneous Fees - 100
Tuition fees [Adjustment] - 0 Application Fee - 0
Tuition fees - 750 Faculty/College Development and Maintenance Fund - 0
University Development and Maintenance Fund - 600 Library & Learning Resources Fund - 0
Internal Assessment Fees - 50 Facilities & Services Charges - 0
Academic Activity Fees - 50 MSU Union Membership Fees - 0
Faculty/College Students Association Fees - 0 Sports & Physical Education Activities Fees - 0
Economically Disadvantaged Students' Support Fund - 100 Examination Fees - 920
Total : 2820
Payment
Amount Transaction Date Transaction Number Transaction Type
Status
2820 Paid 17/03/2021 00:00:00 710541615977179780 Online Payment
4.Guardian Information
Occupation of Guardian : Farmer Annual Income of Guardian : 27000
5.Educational Details
Total
Month Exam
Name of Name of Board/University and Name of Certificate Mark Marks
and Year Seat CGPA %
Examination State of University School/College No. Obtained Out
of Passing No.
Of
GUJARAT SECONDARY AND
HIGHER SECONDARY March
Std 10th -- -- 489.00 600.00 -- - -- 81.50
EDUCATION BOARD, 2015
GANDHINAGAR,
GUJARAT SECONDARY AND
Std 12th 12Th HIGHER SECONDARY March
-- -- 491.00 600.00 -- - -- 81.83
(Science) EDUCATION BOARD, 2017
GANDHINAGAR,
Your Last Qualifying Exam:
7.Other Information
Would you like to apply for Hostel accommodation required NA
DECLARATION
I hereby declare that all the information furnished by me in this application form is true, complete and correct to the best of my
knowledge and belief. I do understand that I need to obtain and produce all the required documents.
I admit to having understood what constitutes ragging and sexual harassment. I have read the guidelines related to the same. I
hereby affirm that if found guilty of ragging or sexual harassment I am liable for punishment according to the university
regulations. "I hereby confirm that I will SUBMIT SYSTEM GENERATED APPLICATION-FORM along with necessary enclosures
required to verify the Academic credentials and Personal details (Like Mark-sheets, Degree Certificates, Caste Certificates-if
applicable…etc.) to the concerned Faculty/College under which I have applied through this application, at the time of "Merit-based
Admission Schedule/Spot Admission Schedule" as available under the Prospectus/Published on the University website as notified
by the concerned Dean of the Faculty/Principal of the College."
I will undergo Thalassemia Test before the First Semester Examination. I hereby declare that I shall refrain from engaging in any
behavior or activity that is prohibited as per the university regulations.
Note: Candidate must carry two copies of above printout of his/her “Application Form” at the time of entrance test/merit based
admissions, along with the self-attested copies of all required documents, as mentioned in the respective prospectus and identical
photograph pasted at the appropriate place.On one copy of the application form , Candidate signs partially on the photograph and
partially out side at the time of handing over the form.
Completing the online application form does not guarantee admission in that particular course/program. All admissions are
through entrance test/merit as per the requirement of the program and faculty norms. See Faculty Prospectus for Details.

Place : Date  :
( Signature of the Candidate )
Document printed on Tue Mar 23 2021 11:29:11 GMT+0530 (India Standard Time)