Application Form No : BKBC/BAF/2022/1015

B. K. BIRLA COLLEGE OF ARTS,SCIENCE &

COMMERCE (Autonomous), KALYAN

Conducted By
Kalyan Citizen's Education Society

(Affiliated To University of Mumbai)

Re-Accredited (3rd Cycle) By NAAC with'A' Grade (CGPA- 3.58)

Application for Admission to BOC&F SEM 1 (2022-2023)

Applicant's Personal Details :

Name of the Student Surname First name Father's name Mother's Name
JADE ROSHNI SURESH SUCHITA

Student Name(MARATHI) जाडे रोशनी सुरेश सुचिता

Gender Female Aadhaar card No. : 532311127337
Marital Status: UnMarried Blood Group: O+

Date of Birth: 18/06/2004 Place Of Birth: KANDIVALI

Place of Birth City: 400101 Place of Birth State: Maharashtra
Place of Birth Tehsil: Kandivali Place of Birth Country : INDIA
Nationality: INDIAN Voter Id:
Category : OBC Religion: HINDU

Caste : OBC Sub Caste: KUNBHI

Mother Tongue: MARATHI Differently Abled: NO
Stream: COMMERCE
Uni. Pre.Reg.No. : D22CQ0033861 Employment Status : NO

Address of Correspondence :
Address OPP BARRACK DATTAWADI
State: Maharashtra District: Thane
Pincode: 421001 City/Town/Village: ULHASNAGAR
Residential Area:

Permanent/Native Address :
Address OPP BARRACK DATTAWADI

State: Maharashtra District: Thane

Pincode: 421001 City/Town/Village: ULHASNAGAR

Residential Area:

Contact Details :

Student's Mobile No : 8855963381 Student's Email Id: roshnijade04@gmail.com

Parent's/Guardian's Mobile No: Parent's/Guardian's Email Id:

Parent's Details:
Name: SURESH Annual Income(Rs.) 70000.00

Occupation BUSINESS Office Address

1. Education Details Section

Year of Name Of Seat Obtained Max

Examination Name of Board Perentage Grade
Passing Institute Number Marks Marks
MAHARASHTRA STATE BOARD OF SECONDARY AND B.K.BIRLA
HSC 2022 M171682 467 600 77.83 0
HIGHER SECONDARY EDUCAT COLLEGE
 2. Last Qualifying Subject Details:

Subject
Obtained Marks Max Marks
Name

Declaration by Student
I hereby declare that, i have read the rules related to admission and the information filled by me in this form is accurate and true to the best
of my knowledge. I will be responsible for any discrepency, arising out of the form signed by me and I undertake that, in absense of any
document the final admission will not be granted and/or admission will stand cancel.

ORDINANCES 0.119 RELATING TO THE ATTENDANCE

Following shall be the minimum atttendance necessary for keeping terms.

FIRST TERM/SEMESTER Three-Fourths of days on which lectures
are delievered.
SECOND TERM/SEMESTER Three- Fourths of days on which lectures are delievered.

ORDINANCE 0.125 - MUMBAI UNIVERSITY

To keep a term an undergraduate must complete to the satisfaction of the principal of course of study at the college prescribed for such
term for the class to which such graduate then belongs. Students who fail to satisfy the condition laid down in ordinance .11,01.20 and 0.125
will not be permitted to appear at the College and University. Students are advised to note that under the power given to the Principal under
satisfactory performance at the preliminary examination is made a pre-condition for being to appear for Examination Non appears or
unsatisfactory performance at Examination will not be excused on Any Ground.

Examination: Absence on Medical or Non-Medical grounds should be supported by medical certificate in case of illness or by Satisfactory
evidence if it is on non-medical grounds. The medical must be informed about leave of absence within one week of Such absence. A student
whose Attendance is consistently unsatisfactory is liable for disciplinary action. Further he/she will not cannot be waived or relaxed in case
of employed students.

IMPORTANT

Ragging is strictly prohibited in the college premises and outside. Student including in ragging other student will be punished as per the
Maharashtra Prohibition of Ragging Act,1999(Mah XXXIII of 1999) published in Maharashtra Govt. Gazzette on 15th May 1999. Such student
will also be expelled from the college and F.I.R. will be lodged with the police against them.
The student found guilty of ragging earlier will not
be admitted in this college.

UNDERTAKING BY THE STUDENT

1. ROSHNI JADE
S.O./D.O. of Mr./Mrs./Ms. FATH
have carefully read and fully understood the law prohibiting ragging and the direction of the
supreme court and the Central/State Government in this regard.

2.I have Read a copy of the UGC regulation Curbing the Menace of Ragging in Higher Education Institutes,2009 and i have carefullly gone
through it.

3.I hereby agree that if found guilty of any aspect of ragging. I May be punished as per the provisions of the UGC/University of Mumbai
Regulation mentioned above and/or as per the law in force.

4.I hereby affirm that i have not been expelled or debarred from admission by any institution.

5.I hereby undertake that i will register my name in the voters list with the State Election Commission, Government of Maharashtra as soon
as I complete the age of 18th Years

Date :

Place :

Student
Signature of
UNDERTAKING BY THE PARENT/GUARDIAN

1.I FATH F.O/M.O./G.O.

have carefully read and fully understood the law prohibiting ragging and the direction of the Supreme Court and the
Central/State Government in this regard as well as UGC Regulation on Curbing the menace of Ragging in Higher Educational Institutes,2009.

2.I assure you that my son/daughter /ward will not indulge in any act of ragging.

3.I hereby agree that if he/she is found guilty of any aspect of ragging, he/she may be punished as per the provision of the UGC Regulation
Mentioned above and/or as per the law in force.

Date :

Place : Signature of Parent/Guardian

UNIVERSITY OF MUMBAI DECLARATION / AN UNDERTAKING FROM THE STUDENT

1.I hereby declare that i have read all the rules and regulations framed by the college authorities as given in college prospectus, which are
presently in force.

2.I hereby declare and undertake to abide by all the mentioned rules and regulations and hereby agree, if admitted,to confirm to them and to
such other rules as may hereafter be made for the smooth functioning of the college.

3.I may not be granted terms or allowed to appear for the College/University Examination if my attendance in lectures and
tutorials/practicals falls short of 75 %.

4.I may not be granted any concession in any matter, if I take up any employment during the course of my studies.

5.I hereby declare that I shall show satisfactory progress and maintain good conduct.

6.I hereby declare that i have not registered my name at any other institution for any other full time course.

7.I hereby declare that the information filled in by me in this form is accurate and true to the best of my knowledge . I Will be responsible for
any discrepancy,arising out of the form signed by me and I undertake that, in absence of any document
the final admission will not be
granted and/or admission will stand cancelled.

8.I WILL DISPLAY MY IDENTITY CARD PROMINENTLY IN THE COLLEGE PREMISES.

9.I have given my and my parents most recent contact details(Phone, Email). In case of any change I undertake to inform college
accordingly.

10.I hereby give my consent for use of my contact details for educational communication.

11.I am aware that as per University Circular No.SW/42 of 2015 dtd. 29th Oct. 2015, I am compulsorily required to give and undertaking on
www.antiragging.in & www.amanmovement.org

12.I will get myself enrolled for Voter ID card when i would turn 18 Years of age.

13.I am aware that if eligible for Scholarship/Freeship scheme of Social Welfare Department then i must complete all the formalities in time.
If i fail to do so then i undertake to pay full fees of course by end of October of the Current Academic year.

14. I have read eligibility conditions of University of Mumbai for my course. My admission will be confirmed subject to confirmation from
University of Mumbai.

Date :

Place :

Student
Signature of
DECLARATION BY PARENT/GUARDIAN

I __________________________________, (Mother/Father/Guardian) hereby fully endorse the above undertaking/declaration

given by my
child/ward. And I will endevor to induce my child/ward to do his/her vest to observe the above stated undertaking in words and spirit

Date :

Place : Signature of Parent/Guardian

3. Attached Documents

Sr No. Name of Documents/Certificate

Note :
Attach the photocopy of the following documents and certificates:

1.X Marksheet.

2.XII Marksheet.

3.For S.Y. Admission- Marksheet of F.Y. Sem I & Sem II.

4.For T.Y. Admission- Marksheet of F.Y. Sem I & Sem II and Marksheet of S.Y. Sem III & Sem IV.
5.Caste Certificate & Caste Validity Certificate(if any).

6.Address Proof(Aadhar Card/ Passport/ Electricity Bill/ Telephone Bill)