Application Form

Please Paste Pasport Size Photograph

Application Number Appilcation type

Student SSC Details

APPK0043883M20092011 New Renewal Course Year N.A

SSC Board Passing Year

Applicant's Details

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2009 SSC Seat No K004388 SSC Marks Obtained 87.23

Applicant Name Date of Birth

CHINMAY
first name

SHIVKUMAR
middle name

SHAHANE
last name

Mother's Name Is Resident of Maharashtra Application Date

VASUNDHARA Maharashtra

18-12-1993

Gender

Male

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

2011-2012 Other Backward Class Sonar (154) No No Is Disabled Applicant's Annual Income Is Staying at Hostel ? Sub Caste No 0.00

04-10-2011

Disability Type

N.A. 324522.00

Total Annual Income Has Applied For Hostel ?

No

No

No

Student Prequalifying Details

Last attended School/College/Institute Last Exam Passed Passed

Institution Details

Deogiri College,Aurangabad Last Exam Passed Year 2011 Last Exam Marks 70

HSC Yes

Name of School/College/Institute where Admitted Course Name Subject College Admission Number Is Fees Paid ? Fee Receipt Date 111013

M.G.M.'s Jawaharlal Nehru Engineering College, Aurangabad-431003

Bachelor of Engineering (Computer Science) Is Admission after Diploma Date Of Admission Fee Paid Course Year No 26-07-2011 Academic Year Joining Date 2011-2012 26-07-2011

No

0.00 1

Fee Receipt No. Quota Government Quota

Contact Details

Residential Number: N.A, MobileNumber: 7276427077, EmailAddress: chinmayshahane11@gmail.com

Address For Correspondence

Address:- RH-13/3,Keshav Nagari,Shahanoorwadi,Aurangabad Location:- Aurangabad Pincode:- 431001 Taluka:- Aurangabad District:- Aurangabad

City:- Aurangabad

Parent / Guardian Details

Parent's name

SHIVKUMAR
first name

Ganpatrao
middle name

SHAHANE
last name

Relation with Applicant Parmanent Address

Father

Parent Age

51

(yrs)

Profession

Service

RH-13/3,Keshav Nagari,Shahanoorwadi,Aurangabad

Parents Annual Income

324522.00

Hostel Information

Name of Landlord / Hostel Hostel Type

N.A

Hostel Admission Date Is Mess Service Available? No 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 Caste Validity Certificate No Income Certificate No University Registration No

6070

District Issuing Office District Issuing Office Issued in

Beed

Taluka Issuing Office Scrutiny Committee No

Bid

F10844

Aurangabad

A209

55354

2011

Student Bank Account Details

Bank Name Branch Name

Bank Account No

Document Attached

Caste Certificate Issued by Competant Officer Income Proof - Income Certificate Issued by Competant Authority Marksheets I-card Size Photo Caste Validity 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