Application Form

Printed on Course 10/15/2013 7:45:06 AM Bachelor of Arts GOI Post Matric Scholarship , 2013-2014 Other Backward Class

Application Number Appilcation type Student SSC Details SSC Board Passing Year

APPC0131221M20102013 Renewal Renewal Course Year 2012

Please Paste Passport Size Photograph

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2010 SSC Seat No C013122 SSC Marks Obtained 59.27

Applicant's Details Applicant Name AMRUTA Date of Birth 09-07-1994 DATTATRAY Gender Maritial Status MALI Female No Mother's Name YUGANDHARA

Is Resident of Maharashtra Maharashtra Caste Category Sub Caste Other Backward Class

Application Date 30-09-2013 Caste Orphan Mali (182) No

Is Disabled Applicant's Annual Income

No 0.00

Disability Type

N.A.

Is Applicant Salaried ? NO Is Staying at Hostel ? No

Total Annual Income 85000.00 No

Has Applied For Hostel ?

Student Prequalifying Details

Academic Year Institute Course Course Year Percentage Result

2012 - 13 2011 - 12 2010 - 11

S.N.D.T.Pune S.N.D.T.Pune S.N.D.T.Pune

B.A. Music 12 th Arts 11 th Arts

1 1 1

62.33 64.83 65.00

Pass Pass Pass

Institution Details Name of School/College/Institute where Admitted Course Name Course Year EID Number Subject Bachelor of Arts 2 CAP Number N.A UID Number S.N.D.T. Arts & Commerce College for Women Pune

2017/90199/49239 20/07/2013 14:11:41 Music Academic Year Admission Dt. Fee Paid GrantType 2013-2014 10-06-2013 0.00 Granted Is Admission after No Diploma Joining Date 15-07-2013 Fee Receipt No. Quota Government Quota

College Adm.No BA014 Is Fees Paid ? Fee Receipt Date Contact Details No N.A

Residential Number: 02024473881, MobileNumber: 8149149804, EmailAddress: amrutamali09@yahoo.in Address For Correspondence Address:- Shukrawar peth Location:- Shivaji road City:- shukrawarpeth Pincode:- 411002 Taluka:- Pune City District:Pune 1 Of 2

Parent / Guardian Details Parent's name DATTATRA sitaram Y Relation with Applicant Father Parmanent Address Is Father Alive Hostel Information Name of Landlord / Hostel Hostel Type Hostel/ Landlord Address Is Studying in night school Document Details Caste Certificate No Caste Validity Certificate No 1750/2008 N.A District Issuing Raigarh Office District Issuing N.A Office Issued in 2013 Taluka Issuing Office Scrutiny Committee No University Registration No Mangaon N.A 130623804 Yes Is Mess Service Available? No Hostel Admission Date Rent Per Month Hostel/Landlord Contact Details 0.00 MALI Age Profession (yrs) Service

Shukrawar peth Location:- Shivaji road City:- shukrawarpeth Pincode:- 411002 Taluka:Pune City District:- Pune Annual Income 85000.00 Yes

Income Certificate 130623804 No Student Bank Account Details Bank Name Branch Name IFSC Code IDBI BANK LTD PUNE SADASHIV PETH IBKL0000548

Bank Account No MICR Code

332104000009355

NOT AVAILABLE

Document Attached EID document xerox I-card Size Photo Marksheets Income Proof - Form 16 Caste Certificate Issued by Competant Officer Declaration The information furnished by me is complete and correct. I bear the complete responsibility for all the above information. Applicant's Signature Principal's Signature _______________________ _______________________ Applicant Parent's Signature _______________________

2 Of 2