You are on page 1of 3

Application Form

Please Paste Pasport Size Photograph Renewal Course Year N.A

Application Number Appilcation type Student SSC Details SSC Board Passing Year Applicant's Details Applicant Name Date of Birth

APPc1058771M20062011 New

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2006 SSC Seat No c105877 SSC Marks Obtained 51.00

GANESH
first name

MAHADEV
middle name

RANE
last name

Mother's Name Is Resident of Maharashtra Application Date

ARUNA Maharashtra

11-05-1990

Gender

Male

Academic Year Caste Category Caste Orphan Is Applicant Salaried ? Maritial Status

2011-2012 Other Backward Class Lonari (183) No No Is Disabled Sub Caste No

20-10-2011

Disability Type

N.A. 179773.00

Applicant's Annual 0.00 Income Is Staying at Hostel ? No

Total Annual Income Has Applied For Hostel ?

No

No

Student Prequalifying Details Last attended School/College/Institute Last Exam Passed Passed Institution Details Name of School/College/Institute where Admitted Course Name Subject Genba Sopanrao MozeTrust's Genba Sopanrao Moze College of Engineering, Pune-411045 DIPLOMA IN E&TC Yes SHRIRAM INSTITUTE OF ENGG TECH(POLY) PANIV Last Exam Passed Year 2011 Last Exam Marks 75

Bachelor of Engineering (ENTC) ELECTRONIC&TEL Is Admission after ECOMMUNICATIO Diploma Date Of Admission Fee Paid Course Year Yes 28-08-2011 Academic Year Joining Date 2011-2012 28-08-2011

College Admission DSE11120331 Number Is Fees Paid ? Fee Receipt Date No

0.00 2

Fee Receipt No. Quota Government Quota

Contact Details Residential Number: N.A, MobileNumber: 9921760006, EmailAddress: ganeshrane1431@gmail.com

Address For Correspondence Address:- A/P-SOPANBAG,BALEWDI,PUNE Taluka:- Haveli District:- Pune Location:- BALEWADI City:- PUNE Pincode:- 411045

Parent / Guardian Details Parent's name MAHADEV


first name

SITARAM
middle name

RANE
last name

Relation with Applicant

Father

Parent Age

45

(yrs)

Profession

Service 179773.00

Parmanent Address A/P-JAWALARJUN TAL-PURANDAR DIST-PUNE Hostel Information Name of Landlord / N.A Hostel Hostel Type N.A Is Mess Service Available? No

Parents Annual Income

Hostel Admission Date Rent Per Month

N.A

N.A

Hostel/ Landlord Address

N.A

Hostel/Landlord Contact Details

N.A

Is Studying in night school Document Details

No

Caste Certificate No MAG/SR/22615/06

District Issuing Office District Issuing Office

Pune

Taluka Issuing Office Scrutiny Committee No

Purandar

Caste Validity Certificate No Income Certificate No University Registration No Student Bank Account Details Bank Name Branch Name MAG/SR/19011/1 11

Pune

Issued in

2011

Bank Account No

Document Attached Caste Certificate Issued by Competant Officer Income Proof - Income Certificate Issued by Competant Authority Marksheets I-card Size Photo District Transfer Certificate Non-Crimiliar Certificate

Declaration The information furnished by me is complete and correct. I bear the complete responsibility for all the above information.

Applicant's Signature

Applicant Parent's Signature

Principal's Signature