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ADMISSION FORM (2022-2023) XII SCIENCE NG

Registration Form No: 22XII01335 Sikh Minority: No

GR NO: 849 Category: General / Open

Date: May 11 2022 17:56:41

1. Personal Information Section

Aadhaar Number:233439133203

Surname: First Name Father’s Name: Mother’s Name:

RAJAN YASH PURUSHOTTAM RAJAN SARIKA RAJAN

Date of Birth:Sep 28, 2004 Place of Birth: Amritsar Gender:Male

Nationality:Indian Blood Group:O+ Mother Tongue: Hindi

Religion:Hindu Sub-Caste: Marital Status:Unmarried

2. Contact Details-
Mobile Number:8452834836 Email id: yashrajn100@gmail.com

Parent’s Mobile Number: 7506449260 Email id: raajanp5@gmail.com

Address:1602, Platino-A, Lodha Splendora, G.B Road, Thane (w)

State: Maharashtra District: Thane

3. Legal Reservation Information
Domicile of State: Parent’s / Guardian’s Occupation: Service Annual Income: ₹ 3500000

Social Reservation Information: None

Declaration by Student and Parent/Guardian

We hereby declare that we have read the rules and eligibility criteria related to admission and the information filled in this form is
accurate and true to the best of our knowledge. We will be responsible for any discrepancy, arising out of the wrong information
furnished and signed by us and we undertake that, in the absence of any document the final admission will not be granted and / or
admission will stand cancelled, under such circumstances we will have no claim against the college.

Place:______________________
_____________________________ ______________________________
Date:______________________ Signature of the Parent/Guardian Signature of the Student
(Sign above the line) (Sign above the line)

FOR OFFICE USE ONLY

Checked by - Signature: Signature of Prof InCharge / Principal Signature of Cashier:

 DECLARATION BY THE STUDENT

I, Mr. RAJAN YASH PURUSHOTTAM RAJAN SARIKA RAJAN of XII SCIENCE NG hereby declare and state as
under:

I understand as per College norms I should regularly attend the lectures / practicals / tutorials and that it
shall not be the responsibility of the college to inform me if I default in my attendance, as prescribed by the
University / Board / College.

I have carefully gone through the College Prospectus and I affirm that it will be my responsibility to ensure
that the internal assessment task will be accomplished by the prescribed date and the college may proceed
to take steps against me if I default in the same.

I have fully understood the eligibility criteria for admission and I have fulfilled the requisite criteria of
qualification for admission.

I understand that my admission in the college will be canceled and/or term will not be granted and/or I will
not be allowed to appear at the Semester examination/s if I fail to have the requisite attendance i.e. 75%
attendance as prescribed by the university and/or for any acts prejudicial to the discipline and reputation of
the college.

I have read and understood the rules of code of conduct of the college and I will abide by the same.

I am very much aware that ragging in any form is strictly prohibited in the college premises and any violation
of the same on my part will be liable for stringent disciplinary action against me as per the directive of
Hon'ble Supreme Court.

Place:____________________ _______________________________
Date:_____________________ (Signature of the student)

PARENT'S DECLARATION
I have gone through the declaration given by my ward hereinabove and understood the contents therein. I hereby assure
that I shall constantly monitor my ward's academic performance by regular visits to the college.

Place:____________________ _______________________________
Date:_____________________ (Signature of the Parent /Guardian)