8/29/23, 3:24 PM form No.

11043

BARRACKPORE RASTRAGURU SURENDRANATH COLLEGE

AFFILIATED UNDER WEST BENGAL STATE UNIVERSITY

APPLICATION FOR PROVISIONAL ADMISSION FORM (SESSION :2023-24 FOR SEM I)

if at any stage of admission process, the marks entered in this online system is found incorrect the
application will be rejected and no claims of repayment of application fees will be entertained.

Student ID: signature

Form No : BRSNCUG2311043 Ackd No. : BRSNC2210998 Date: 29-08-2023

Full Name : J A Y E E T A C H O W D H U R Y

Father/Guardian Name : J A Y A N T A C H O W D H U R Y

Mother's Name : S W A T I C H O W D H U R Y

Blood Group : A- Gender : M Category : GEN

Religion : Hinduism PH : NO DOB :  27-9-2003

F-57/208/804/1006 RATHTALA
Address KANCHANPALLY LANE KALYANI Guardian's Qualification Ucchha Madhyamik
KALYANI KALYANI NADIA

Country INDIA Family Income 20000 and Above

State WEST BENGAL Mother Tongue Bengali
District NADIA Email ID chowdhuryjayeeta26@gmail.com
Pin No. 741235
Block Municipality / Panchayat KALYANI MUNICIPALITY

Mobile No. : 9 8 7 5 3 0 0 1 2 7 Whatsapp Number 9 8 7 5 3 0 0 1 2 7

Details of H.S. or equivalent (10+2) Exams :

Board/Council (10+2) : WEST BENGAL COUNCIL OF HIGHER SECONDARY EDUCATION
KANCHRAPARA SARADA DEVI UCHCHA
School / Institute Name : HS Registration No : 4202283021
BALIKA VIDYALAYA
Roll /Index Number : 4610211625 Passing Year of HS : 2022
Details of H.S. or equivalent (10+2) Exams Results (Subject Wise) :

  Language Name of other 4 subjects below

ENVIRONMENTAL POLITICAL
Subject BENGALI ENGLISH HISTORY NUTRITION
STUDIES SCIENCE

Th Pr Th Pr Th Pr Th Pr Th Pr Th Pr
Marks
37 18 50 18 40 20 28 19 41 29 24 18

Total Best 4 Marks 253 Merit Score 253

Programme Type : UG Multidisciplinary Programme Com Code : 005

CORE 1: HISTORY / CORE 2: BENGALI / CORE 3: EDUCATION

VAC1 : ENVIRONMENTAL STUDIES / VAC2 : VALUE OF YOGA AND MEDITATION IN LIFE
AECC1 : ENGLISH / AECC2 : BENGALI
  Other Activities (Offered by the College) :
1. Add-on Course [On Communicative English, General Mathematics & General Aptitude YES
 
(Course Fee- Rs. 2000/- For 3 Years)] :    
  2. Web Designing Cerificate Course [Course Fee- Rs. 2000+18℅ GST] :     NO
  3. Participation in Co curricular Activities :     NSS
If any information is found incorrect at the time of verification, the admission will be cancelled and the amount deposited will be forfeited.  
If admitted, I also agree to abide by all rules and fee-related guidelines for the course of study that are periodically communicated to me by the
college authority.
Date : Signature of Guardian   Signature of Student

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