MAHARASHTRA STATE BOARD OF SECONDARY & HIGHER SECONDARY EDUCATION, PUNE 411 04

APPLICATION FOR ADMISSION TO H.S.C. EXAMINATION OF FEB-MAR/SEP-OCT 20……

1 College Index No. 2 Appl.Sr.No 3 Centre No.

4a Last Name
CANDIDATE ‘S
b First Name
PHOTO
c Middle Name

d Mother's Name

Residential
5
Address

6 Date Of Birth 7 Aadhar No : - - SIGNATURE OF CANDIDATE

(*Optional)

8 Stream 1) Science O 2) Arts O 3) Commerce O 4) HSC VOCATIONAL O

9 Gender 1) Male O 2) Female O
If Belongs to
10
Minority Religion 0) Non-Min O 1) Muslim O 2) Christian O 3)Buddhist O 4) Sikh O 5) Parsi O 6) Jain O
11
Caste
1) SC O 2) ST O O 3) VJ(A) 4) NT(B) O 5) NT(C) O 6) NT(D) O
7) OBC O 8) SBC O 9) OPEN O 10) MARATHA (ESBC) O 11) MUSLIM (SBC-A) O
Handicapped or Not 0) No Handicapped O 1) Blind O 2) Deaf O 3) Dumb O
12
Handicapped 4) Orthopaedically Handicapped O 5) Spastic O 6) Learning Disable O
13 Medium of Instruction
1) English O 2) Marathi O 3) Gujarati O 4) Kannada O
5) Urdu O 6) Sindhi(Arabic) O 7) Sindhi(Devnagari) O 8) Hindi O
A 1) Fresh O 2) Repeater O
B 1) Regular O 2) Private O 3) Isolated O 4) Class Improvement O
Category of
14
Candidate C 1) Exempted O 2) Non Exempted O
D 1) Agriculture O 2) Bifocal O 3) ITO 4) General O
E Whether foreigner 1) Yes O 2) No O
15 Subject Details
Lang *Exempted Subject information
Sr. Subjects of
No. Ans (Previously Passed Subjects in which candidate widh to claim exemption
Name Code code Seat No Month Year Marks Obt
1 Com English 0 1 Feb O Oct O
Subj
2 Feb O Oct O
3 Feb O Oct O
4 Feb O Oct O
Opt.
5 Subj Feb O Oct O
6 Feb O Oct O
7 Feb O Oct O
8 Com Environment Education 3 1 Feb O Oct O
Subj
9 Physical Education 3 0 Feb O Oct O
NOTE:Please write 9 in case of exemption of column ‘Lang of Ans code and provide information in column under exempted subject information
16 Total No. of Exemption Claimed
17 Enrollment Certificate No.(Private Candidate) 1)FEB O 2)OCT O Year Enrollment No.

18 Eligibility Certificate No. 1)Provisional O 2)Final O Certificate No.

19 Previous Exam Seat. No. Month Year Name of board / Jr. College
Examination SSC Mar O Oct O
Passing Details XI
th
Mar O Oct O
20 Last Exam Seat No.(For Repeaters Only) 1)Mar O 2)Oct O Year Seat No

21 Whether S.S.C. Examination passed from Maharashtra State Board of Secondary & Higher Secondary Education,Pune Yes O No
22 Undertaking by Candidate/Head of Institution
(i) I the undersigned hereby apply for the admission to the HSC EXAM March/September 20…… I
agree to abide by the regulations and all instructions issued by the Board time to time. I am aware of
the scheme of subject combination and examination of the Board approved by the Government and I
agree to abide by the decision of the Board to treated the performance of the subject as cancelled if
wrong combination of subjects if offered. (ii) I have received a copy of the INSTRUCIONS TO THE
CANDIDATE and undertake to abide by them (iii) I have received a receipt of the EXAMINATIO
FORM and EXAM.FEE from the Head of the Institution.
O
(१) मी खाल सह करणार उच मायमक शालांत माणप परा माच/सट बर २०..... वेश अज
करत आहे . मंडळाने वेळोवेळी (नगमत केलेले सव (नयम आ*ण सुचनांचे पालन कर,यास माझी
सहमती आहे . शासनाने मा.य केले/या मंडळाया परा व 0यासंबंधीया 2वषययोजना याची मला
मा4हती आहे आ*ण मी चुक5ची 2वषययोजना (नवडल असेल तर 0या 2वषयांची संपदणूक र8
कर,यासंबंधीचा मंडळाचा (नणय माझेवर बंधनकारक असेल. (२) उमेदवारासाठ:या सूचनांचे प मला
ात झाले असून ते मा;यावर बंधनकारक राहल. (३) सं<था मुखांकडू न मला आवेदनपाची आ*ण
परा शु/काची पोहोच पावती ात झाल आहे .

Place Date : Signature of Candidate <थळ: 4दनांक: उमेदवाराची <वार

(i) I hereby certify that the information given by the candidate has been verified by me and is found
to be correct. (ii) I certify that a receipt of EXAMINATION FORM and FORM FEE along with the
INSTRUCTIONS TO THE CANDIDATE have been given to the candidate. (iii) I certify that the
candidate is eligible to appear for H.S.C. exam as per Boards regulations.
(१) उमेदवाराने 4दले/या मा4हतीची मी पडताळणी केल असून ती बरोबर अस/याची खाी क>न
मा*णत करत आहे . (२) आवेदनप व परा शु/क आ*ण उमेदवारासाठ:या सूचनांची पोहोच मी
संबं?धत उमेदवाराला 4दल आहे . (३) मंडळाया (नयमांनुसार उमेदवार उच मायमक शाला.त
माणप परा 2व@ठ हो,यास प अस/याचे मी मा*णत करत आहे .

Signature and Seal of the Head of the Institution मुयायापकाची वार व शाळे चा शका
PDBEDP/APPLICATIONS/HAPPL_HSC_M16.PDF