P.E.S.

’s Modern Institute of Computer Application Yamunanagar, Nigdi, Pune – 411044

Student Registration Form - Academic Year: 2020-21
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Google Forms <forms-receipts-noreply@google.com> Wed, 12 Aug, 2020 at 4:47 pm

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Application Yamunanagar, Nigdi, Pune – 411044
Student Registration Form - Academic Year: 2020-21
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P.E.S.’s Modern Institute of Computer

Application Yamunanagar,
Nigdi, Pune – 411044 Student
Registration Form -
Academic Year: 2020-21
Student Registration Form -(All the information to be filled in capital letters only)

Email address *

sdawale333@gmail.com

Name of Student: *

Shivam Vitthalrao Dawale

Father’s Name: *

Vitthalrao Dawale

Mother's Name: *

Lalita Dawale

Admission Date: *

DD MM YYYY

12 / 08 / 2020

Academic Year: (Select year) *

MCA First Year

MCA Second Year

MCA Third Year

Admission Category: *

SC

ST

NT/VJNT

OBC

EBC

OPEN

OMS
Religion *

Hindu

Caste: *

OBC

Nationality: *

Indian

Address Details: (Local Pune Address) *

near mahadev mandir yamuna nagar nigdi pune 411044

Address Details: (Permanent Address) *

at Wai mendhi Post Lakh Rayaji Tal Digras Dist Yavatmal

State: (Permanent Address) *

Maharashtra

District : (Permanent Address) *

Yavatmal

City : (Permanent Address) *

Digras
Student's Contact Details: (Phone / Mobile No. ) *

9921389325

Father's Contact Details: (Phone / Mobile No. ) *

9604527396

Student's Contact Details: (Email ID ) *

sdawale333@gmail.com

Fees- Amount Paid:( in Rs. ) *

31088

Fees- Amount Paid Details:( Bank Transaction Details UPI/UTR No. ) *

UTR No: BKIDN20225301272

Fees-Paid ScreenShot of payment: (Upload JPG/PDF File eg. File Name should be
as 'yourname_Fees' ) *

Submitted files

ShivamDawale_Fees - Shivam Dawale.jpg

Student's Photo :(Upload JPG File eg. File Name should be as 'yourname_Photo' ) *

Submitted files

ShivamDawale_photo - Shivam Dawale.jpg

 Student's Signature: (Upload JPG File eg. File Name should be as 'yourname_Sign' )
*

Submitted files

ShivamDawale_sign - Shivam Dawale.jpg

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