Application Form

Printed on Course 7/11/2012 12:50:24 PM Master of Science (Computer) GOI Post Matric Scholarship , 2012-2013

Application Number Appilcation type Student SSC Details SSC Board Passing Year

APPL0211118M20062012 Renewal Renewal Course Year 2011

Please Paste Passport Size Photograph

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2006 SSC Seat No L021111 SSC Marks Obtained 72.26

Applicant's Details Applicant Name BABASAHEB Date of Birth 10-06-1990 RAMESH Gender Male No KAMBLE Mother's Name TARABAI

Is Resident of Maharashtra Maharashtra Caste Category Sub Caste Scheduled Caste N.A N.A.

Application Date 03-07-2012 Caste Orphan Mahar (37) No

Maritial Status

Is Disabled Applicant's Annual Income

No 0.00

Disability Type

Is Applicant Salaried ? No Is Staying at Hostel ? No

Total Annual Income 41000.00 No

Has Applied For Hostel ?

Student Prequalifying Details

Academic Year Institute Course Percentage Course Year Result

2011 - 12

SRTMUN SUB-CENTRE ,PETH,LATUR

Master of Science (Computer)

0.000

Pass

Institution Details Name of School/College/Institute where Admitted Course Name Subject SRTMUN SUB-CENTRE ,PETH,LATUR CAP Number 2012-2013 02-07-2012 0.00 GrantTyp Granted e Is Admission after Diploma No Joining Date Fee Receipt No. Quota Government Quota 03-07-2012

Master of Science (Computer) SE NE IT CM Academic Year Admission Dt. Fee Paid Course Year 2

College Adm.No 05 Is Fees Paid ? Fee Receipt Date Contact Details No N.A

Residential Number: N.A, MobileNumber: 8149626612, EmailAddress: kamblebr1@gmail.com Address For Correspondence Address:- AT YELWAT POST KILLARI TQ AUSA DIST LATUR Location:- YELWAT City:- YELWAT Pincode:413516 Taluka:- District:- Latur

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Parent / Guardian Details Parent's name RAMESH DAMU KAMBLE Age Profession 49(yrs) Labor

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 NO District Issuing Latur 2006/MISC/WS734 Office N.A District Issuing N.A Office Issued in 2011 No Is Mess Service Available? No AT YELWAT POST KILLARI TQ AUSA DIST LATUR Yes

Annual Income 41000.00

Hostel Admission Date Rent Per Month Hostel/Landlord Contact Details N.A

Taluka Issuing Office Scrutiny Committee No University Registration No

Ausa N.A 200801680018024 4

Income Certificate 689 No Student Bank Account Details Bank Name Branch Name IFSC Code

BANK OF MAHARASHTRA V C LATUR MAHB0001133

Bank Account No MICR Code

25005888937

NOT AVAILABLE

Document Attached Caste Certificate Issued by Competant Officer Income Proof - Income Certificate Issued by Competant Authority Marksheets I-card Size Photo 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 _______________________

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