Form No. :2037511 Seva Sadan's Receipt No.

________

R.K. TALREJA COLLEGE OF ARTS, SCIENCE & COMMERCE

ULHASNAGAR - 421 003.
PRN.: APPLICATION FOR ADMISSION 2020-2021

Fee Type : XI COMMERCE Div : Roll No.

Category : Girls Freeship Date of Birth : 31/07/2004

(as per School Leaving Certificate)
Religion : OPEN
Gender : F
Caste : GENERAL
Aadhar Card No. : 894938477561
Physically Challenged : No
Total Annual Income : 60000.0
Type Of Disability :
Application Form NO.: MU1132868
Percentage Of Disability :
(as per School Leaving Certificate)
(Attach Necessary Certificates)

No. of Child : 2

Blood Group : O+

Particulars:

1) At the desire of my Parent/Guardian, I wish to apply for admission to FYJC / XI COMMERCE

2) Full Name : CHAUHAN CHETANA RAJENDRA Email Id : 3) Place of Birth :

chetanachauhan19
7@gmail.com

AMBERNATH Taluka :

AMBERNATH Dist : THANE State : MAHARASHTRA Place of Domicile

:

MAHARASHTRA 5) Nationality : Indian

6) Local Address : 4174, Bhaskar Nagar, Opp Pachim Pan Shop, Ambernath west, Phone :
AMBERNATH, MAHARASHTRA
Mobile : 8482801310 7) Permanent Address (Native Place) :

, 4174, Bhaskar Nagar, Opp Pachim Pan Shop, Ambernath west Taluka : , AMBERNATH

Dist : THANE State : MAHARASHTRA I Desire to offer the following subjects :

1. ENGLISH
2. HINDI
3. ENVIRONMENTAL STUDIES
4. ORGANISATION OF COMMERCE
5. BOOK KEEPING
6. ECONOMICS
7. MATHS
8. PHYSICAL EDUCATION

I have passed the SSC Examination held in March/October 2020 with the 1 attempt with /without exemption from 6571 Center
under Seat No. A080291

8) I give, in the table below, information regarding examinations I have passed :

Degree/Diploma Name of Name of College Year Month of Marksheet Seat No. No of Attempts / Total Marks/Out of Class/Grade
Certificate Course Board/University from which Passing Centre No Obtained
appeared

SSC Or Equivalent MAHARASHTRA SHASHTRI HINDI MARCH 2020 A080291 1 / 6571 391/500 78.20
STATE BOARD VIDYALAYA

XIth Or Equivalent /

10) Immediately previous to this I attended STD XI class in the year and my Roll No. from school

11) U DISE No. Of School 27211511005

12) I represented my school in following
games :

13) I joined N.C.C. in __________ and hold the rank as __________

14) I enclose herewith Two duly attested Xerox Copies of Following documents :

i) Marksheet of X or XI

ii) For EBC/PTW/STW/Ex.Serviceman and Reserved Category students only. Xerox copies of

1) Caste Certificate 2) Ration Card 3) Income certificate or Certificate Issued by Tehsildar 4) School Leaving
Certificate 5) Domicile Certificate if the candiate is other state.

15) Bank Details :

Bank A/c No. Name of the Bank

Branch IFSC Code :

DECLARATION

I have read all the rules and regulations in force at present an hereby agree. If admitted to confirm to and to such other rules as
may hereafter be made for the orderly Governance of the College.
I promise that, while, I am student of R.K.Talreja College, Ulhasnagar-3, I shall do nothing to obstruct or interference in any with
its orderly governance of discipline, and that I shall devote my entire attention to the futherance of studies. I will attend
minimum 75% of lectures and practicals in both the terms.
I also promise that I shall inform the Principal in writing in case I decide to discontinue my education or college in the middle of
the year.

Date : 31/08/2020 Signature of Student

ENDORSEMENT BY PARENT/GUARDIAN
1) Name of Father : RAJENDRA

2) Occupation: LABOUR

3) Office/Shop Address :

4) Fathers Mobile : 7057054116 Mothers Mobile :

5) Email Id : chetanachauhan197@gmail.com

The applicant is my son / daughter / ward. The information submitted above is correct. I endorse the application and
declaration made there in.
I agree to pay additional fees as and when revised by Govt. and college authorities

Date : Signature of Parent / Guardian

FOR OFFICE USE ONLY

Admitted / Not Admitted Accept Rs._________

Principal's Signature