8/22/13 UGC_Student_Affidavit_Registration_Page

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ANTI RAGGING AFFIDAVITS BY STUDENTS AND PARENTS/GUARDIANS

Fields marked with red* are compulsory.

Personal Details

Student's Family Name * SHENDGE

Student's Middle Name Enter your Middle Name

Student's First Name * PARSHURAM

Gender * Male Female

Nationality * INDIAN

Student's Mobile Number* +91 1234567891

Student’s friends Mobile number in case of an emergency * +91 1231457895

Landline Number * +91 22 21234568

Student's email ID * parshuramns@gmail.com

Confirm student's email ID * parshuramns@gmail.com

NIWARA CO.OP.SOC., C-13/02, SECTOR-46,

NERUL, NAVI MUMBAI-400706
Permanent Address 1 *

Enter your Address2

Address 2

City * Navi Mumbai

State * Maharashtra

Parent/Guardian Details

Parent/Guardian’s name* Mr. Nivrutti Shendge

NIWARA CO.OP.SOC., C-13/02, SECTOR-46,

NERUL, NAVI MUMBAI-400706
Parent/Guardian Address 1*

Enter your Address2

Address 2

City * Navi mumbai

State * Maharashtra

Residence Phone No *
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Residence Phone No * +91 22 21234568

Mobile No of Parent/Guardian* +91 1237894561

Parent/Guardian’s Email ID * parshuramns@gmail.com

College Details

State in which the College is * Maharashtra

Is it a Professional College or a General College * Pharmacy

Name of the College * NCRD's Sterling Institute of Pharmacy

Name of Affiliated University * Mumbai University

It is Deemed University * Yes No

Director/Principal Family Name* Mr. GADGE

Director/Principal First Name * Dr. MADHUSUDAN

Director/principal Gender * Male Female

College Phone No. 1* +91 22 27715308

College Phone No. 2 +91 Enter College Phone No.

Nearest Police station Name and Address * Nerul Police Station, Jagadguru Shri Shankaracharya Marg, Sector 23, Nerul, Navi Mumbai- 400 706

Course Details

Under Graduate or Post Graduate * Under Graduate Degree

Name of the Course * BACHELOR OF PHARMACY

Your Registration/Enrolment Numbernt Number* 123456

How many students are in your Class * 60

Year of Study* 1

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Fields marked with red * are compulsory.

National Anti-Ragging Helpline (UGC Crisis Hotline) - 24x7 Toll Free Number* 1800-180-5522
(helpline@antiragging.in)

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