KARMAVEER BHAURAO PATIL JUNIOR COLLEGE

College Code:

KBPJR
PKC Road, Sector 15-A, Juhu Nagar, Vashi, Navi Mumbai,
Maharashtra 400703 Application No.:

22XISCI70

For College use Course Applied For: XI SCIENCE (AIDED) Registration No.

only 2082578
Medium: ENGLISH

Registration Date: 07/08/2022

1. Personal information section

Last Name First Name Middle Name

Name of Student MANE PRAJAKTA DATTATRAY

Father's Name DATTATRAY YASHWANT MANE

Mother's Name: SHOBHA In-House Student: NO

Marital Status: Saral No.: 2012272110052020049

Date of Birth: 12/08/2006 Gender: FEMALE

Place of Birth: MANEWADI Blood Group: A+

Aadhaar card No.: 608164988359 Native Place: Government Form Application No(MU No).
: 222058995

Bank Name: Account No.: Eligibility No.:

Religion: HINDU Nationality: INDIAN Driving Licence No.:

2. Address Details

Address of Correspondence: BULD NO. 637, 638, 639 , ROOM NO. 301, MAULI KRUPA, Pin Code: 400703
JUHUGOA, VASHI NAVI MUMBAI 400703

State: MAHARASHTRA District: THANE Tehsil: City: JHUGAON

Permanent Address: BULD NO. 637, 638, 639 , ROOM NO. 301, MAULI KRUPA, Pin Code: 400703
JUHUGOA, VASHI NAVI MUMBAI 400703

State: MAHARASHTRA District: THANE Tehsil: City: JHUGAON

3. Contact Details

Student Mobile No.: 9619797135

Student Email Id: PRAJAKTAM303@GMAIL.COM Parent phone: 9960290700

4. Legal Reservation Information Section

Domicile state: MAHARASHTRA Admission Category: OPEN Caste Category: OPEN

Caste: HINDU MARATHA Phy. Handicapped:

Caste Certificate No.: Learning Disability No.:

5. Social Reservation (Special Category) Information Section

SR No. SOCIAL RESERVATION NAME

6. Education Details Section

Name of Name of Name of Date of Examination Seat Passing Grade/Total Obt.

% CGPA
Examination Board school/College Passing Number certificate No. Marks Marks
 7. Qualifying Exam Details Section

QUALIFYING EXAM NAME: 10TH

College/School Admission Passing Marks Total Education

Board/university Percentage Place Arts/Com/Sci
Attended Year Year Obt. Marks Gap
MAHARASHTRA STATE VASHI NAVI
ICL HIGH SCHOOL 0 2022 430 500 86 NO
BOARD MUMBAI

Qualifying Exam Subject Details

Sr. No. Subject Name Total Marks Obtained Marks

8. Subject Details Section

Sr. No. Group Name Subject Name

1 HINDI BIOLOGY,CHEMISTRY,ENGLISH,ENVIRNMENT EDUCATION,HEALTH AND PHYSICAL EDUCATION,HINDI,MATHEMATICS,PHYSICS

9. Attached Documents

Sr No. Name of Documents/Certificate

1 10TH MARKSHEET

2 SCHOOL LEAVING CERTIFICATE

3 (11TH) ONLINE REGISTRATION FORM PART - 1 AND PART - 2

4 AADHAR CARD

10. Guardian / Parent Information Section

Guardian's/ Parent's Name:

DATTATRAY YASHWANT MANE

Occupation of the Guardian/Parent: Annual Income of the guardian/Parent:

300000.00

Relationship of Guardian with applicant:

-- Guardian/Parent Phone No.:
9960290700

11. Other Information Section

Mother Tongue: Employment Status:

NO

Would you like to apply for Hostel:

NO

Hobbies, Proficiency and Other interests:

NA

Games and sports participation:

Identification Mark 1:
--

12. Declaration by Student

I hereby declare that, I have read the rules related to admission and 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 cancel.

Place:

Date:

Student
Signature of

13. Declaration by Guardian / Parent

I have permitted my son / daughter / ward to join your college. The

information
 supplied by him / her is correct to the best of my knowledge. I have acquainted myself with the rules and
fees,
dues to my son/daughter/ward and see
that he/she observes.

Place:

Date: Signature of the Guardian/Parent

14. For College / Institute Use Only

Designation Remarks / Particular / Recommendation Signature and Date

Admission Clerk

Admission Committee

Accountant / cashier

Registrar/Office
superintendent

Transaction Details Payment Mode:

ONLINE Cash Received:
100 Transaction ID.:
PUVISC40204988395

REMARK OF THE ADMISSION COMMITTEE

May be admitted to Class__________________________________________________________________

Section___________________________

May be

Rejected_______________________________________________________________________________________________________________

Last date of payment of

fees___________________________________________________________________________________________________

Admission may be cancelled if the fees are not paid by this date.

Principal
Signature of Admission Committee

Date:

Print Date : 07/08/2022