Admission Form English1 1 A4
Admission Form English1 1 A4
Admission Form English1 1 A4
Form No:
Kindly read important notes before filling-in form: 1. Use black ink to fill in the form and Do NOT overwrite. 2. Fill in all fields in CAPITAL letters only. 3. Strike-off whichever is NOT applicable. E.g. If you are a Male :-> Gender: Male / Female
Please paste a passport size (35 mm X 45 mm) Photograph here, Do NOT staple. Photo should not exceed the borders.
Course applied for (e.g.BA/BCom/BE): Course Part or Semester applied for (e.g. 1/2/3/4): Student should sign strictly inside this box only with black ink
Applying for Concession EBC / SC / ST / NT / OBC / SBC / PTC / STC / Freedom Fighter / Ex Service Man : Admitted against which Category : Open / Reserved If Reserved, Specify:
Name of the Student as printed on std. 10 Passing Certificate Fathers/Husbands Name: Mother's Name: Previous name of the Student:
(In case of changed name)
Reason for name change: Willingly / After Marriage Date of Birth (DD/MM/YYYY): / / Place of Birth: Religion:
Marital Status: Unmarried / Married/Divorced/ Widowed/Desserted Gender: Male / Female Blood Group (with Rh): Citizen of (country name):
Address (House no, street/area/suburb etc.) PIN Code: Permanent Address [Write only if different than Address for Correspondence] State: District: Address (House no, street/area/suburb etc.) PIN Code: Contact Details Phone # 1: STD Code: Mobile number: Domicile of State: Caste: Phone No: Email ID: Phone # 2: STD Code: Phone No: Tehsil: City/Town/Village:
3. Social
Ex-Serviceman/Ward of Ex-Serviceman Active-Serviceman/Ward of Active-Serviceman Freedom Fighter/Ward of Freedom Fighter Ward of Primary Teacher Ward of Secondary Teacher Deserted/Divorced/Widowed Women
Form No. :
[Write YES in last column, against the qualifying examination, on basis of which you are seeking admission to the said course write NO in front of th other examinations] Please Note: 10 Details are mandatory in any case Last College Attended: Year: Roll No.:
Name of Board /University Name of School/College Date of Passing (DD/MM/Y YYY) Examination Seat No. (Last) Degree / Passing Certificate No. Grade / Total Marks Obtained Out of Qualifying Examination? (YES/NO)
Std 10 th Std 12
6. Selected/Opted Papers Section [Write paper codes or Paper Name only, in the boxes] Year/ Semester: 1/3/5/7 Semester: 2/4/6/8 (If decided in First Semester only) 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 7. Attached Documents and Certificates Section
Sr. No. 1 2 3 4 5 6 7 8 9 10 Name of Document/Certificate th * Passing Certificate of Std 10 Passing Certificate of Std 12 / Statement of Marks of Std 12 Leaving Certificate Certificate of Caste with Category Non Creamy Layer Certificate Affidavit for changed name/ Marriage Certificate / Govt. Gazette Domicile Certificate Certificate for Physically Challenged
th th
Original / Attested True Copy Attested True Copy (Mandatory) Attested True Copy Original Attested True Copy Attested True Copy Original Attested True Copy Attested True Copy
Attached (Yes/No)
9. Declaration by Student
I hereby declare that, I have read the rules related to admission and the information filled in by me in this form is accurate and true to the best of my knowledge. I will be responsible for any discrepancy, arising out of the form signed by me and I undertake that, in absence of any document the final admission will not be granted and/or admission will stand cancel. I am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that I will abide by all the rules and regulations of the said Act.
Place: Date: Signature of the student:
Note: Student MUST retain photocopy of completely filled in admission form (both pages) for future reference. Available information in this form will be required to activate his/her account on Digital University Portal.