MAHARAJ VINAYAK GLOBAL UNIVERSITY

University Campus : Dhand, Amer, Jaipur-Delhi Highway No 11-C Jaipur

Tel: 01426-284175,284176,284407 Website:www.mvgu.ac.in
Application Form For Admission

Receipt No. 36561

Form Fee Amount 1 Rs.

Date Of Submission 30-10-2021

College Jaipur Occupational Therapy College

Course Master of Occupational therapy

Student Name BARSA RANEE SAMAL

Batch 2021-2022 Session 2021-2022

Gender Female DOB 14-10-1995

Category Gen Nationality Indian

Email barsaranee526@gmail.com Mobile 8658432228

Blood Group Don't Know Fathers Name MAKUNDA CHANDRA SAMAL

Fathers Email barsaranee526@gmail.com Fathers Mobile 8658432228

Occupation SERVICE Income 1.5-3 lac Annum

Mothers Name MANORAMA SAMAL State Odisha

Permanent QTR NO. M/382, N S NAGAR, BHARATPUR, Permanent ANGUL

Address SINGIDA (SANA), NEHRU SATABADI District
NAGAR(BHARATPUR), ANGUL,
ODISHA-759148

Permanent State West Bengal Permanent India

Country

Permanent 759148 Present Address QTR NO. M/382, N S NAGAR, BHARATPUR,

PinCode SINGIDA (SANA), NEHRU SATABADI
NAGAR(BHARATPUR), ANGUL,
ODISHA-759148

Present District ANGUL Present State West Bengal

Present Country India Present PinCode 759148

Aadhar Card 305343382826 Scholarship No

Details of Qualifying Examination:

S. No. Subject 10 + 2/ Graduation / Post Graduation
MaxMarks MinMarks MarksObt
1 BACHELOR OF 3650 1825 2056
OCCUPATIONAL
THERAPY
2
3
 4

Details of Examinations Passed (For Medical as well as Non- Medical students):

Name of Name of the Month/ Year of Maximum marks Marks Obtained % of Marks &
Examinations University/ Board Passing Division
Matric/Secondary(10 BSE 2011 600 451 75.16666666666667
th)
Sr. Secondary ODISHA 2013 500 246 49.2
(10+2)
Graduation CHSE 2020 3650 2056 56.32876712328767
Masters Degree ODISHA

LIST OF DOCUMENTS ATTACHED WITH THIS ADMISSION FORM::

a. Marksheet or b. c. Caste Certificate d. Graduation e. Graduation g. Others
Passing Certificate Marksheet/Passing Marksheet Degree
Certificate of Class
12th
"Yes" "Yes" "No" "Yes" "Yes" "Yes"

DECLARATION BY THE CANDIDATE

1. I have read the Rules and Regulations regarding Admission in concerned programme in the college of Maharaj Vinayak Global University,
Jaipur. I find myself eligible for the same.
2. I do solemnly affirm that the statement and information furnished by me as above and also in the enclosures submitted are true. I realize
that if any information furnished therein is found to be untrue in material particulars. I shall be liable to criminal prosecution as well as to forgo
my admission and to be removed from the college, if already admitted. I shall abide by the decision of the Director / Principal/ Registrar.
3. I also undertake to pay the University, College, Hostel and other dues regularly on the prescribed due date.
(a) I hereby agree, if admitted, to abide by the rules and regulations at present in force or those that may hereafter be made for the
administration of the University/College and I undertake that so long as I am a student of the College, I will do nothing either inside or outside
the University/College that will interfere with its orderly working and discipline.
4. I also declare that:
(a) I have not been convicted of any criminal offence nor have I been released on bail in connection with a criminal case.
(b) No case of criminal offence or moral turpitude is pending against me in any Court of Law.
(c) No complaint or F.I.R. has been lodged against me by the University/ Principal of a constituent College/School.
(d) I have not resorted to any act of indiscipline during the past year.
(e) I have not been debarred from appearing in any of the Entrance Exam/Public Examination.
5. I know that the admission right is reserved with Management and University and merly filling this form does not indicate that my admission
is confirmed

Signature of the Candidate

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