ADM FR / 15

Manisha Education Trusts

College Code: 611

Smt. Jankibai Rama Salvi College Of Arts Commerce & Science

Manisha Nagar, Kalwa(W), Thane 400605 An !" #00$%&00' (erti)ied (ollege
For college use only Course Admitted to: Admission date: & & Division: Roll No: Form No: Pleas e paste a passport size (35 mm X 45 mm) Photograph here, Do NOT staple P hot o sh o! ld " ot e#$ eed t he %orders

Kindly read important notes before filling-in form: 1 'se %la $( i"( to ) ill i" the )orm a"d Do NOT o*er+rit e , -ill i" all )ields i" CA !TA" letters o"l. 3 /tri( e0o)) +hi$he*er is NOT appli$a%le E.g. If you are a Male :-> 1e"der: 2ale & -emal e

Course applied for #e$g$%A&%Com&%'(:

Course art or )emester applied for #e$g$ *&+&,&-(: Applying for Concession '%C & )C & )T & NT & O%C & )%C & Admitted against 1.ic. Category : Ope" & 3es er*ed

/t!de"t sho!ld sig" stri$tl. i nside this %o# o"l. +ith %la$( i"( TC & )TC & Freedom Fig.ter & '/ )ervice 0an : !f Reserved2 /pe$ i).:
First Name Middle Name

*$

ersonal !nformation )ection

Last Name

Name of t.e )tudent:

(4" $ase o) $ha"ged "ame, +rite $!rre"t "ame) of t.e )tudent: (4" lo$a l Name la"g!age)

Name of t.e )tudent as printed on std$ *3 assing Certificate Fat.er4s&5usband4s Name: 0ot.er6s Name: revious name of t.e )tudent:
(4" $ase o) $ha"ged "ame)

Reason for name c.ange: 5illi"gl. & 6)ter 2arriage 0arital )tatus: '"married & 2arried&Di*or$ed& 5 ido+ed&Desserted Date of %irt. (DD&22&7777): & & 7ender: 2ale & -emale lace of %irt.: Religion: %lood 7roup (+ith 3h): Citi8en of ($o!"tr. "ame):

)tudent4s location Category: 3!ral& 'r%a"& Tri%al

Address for Correspondence )tate: Address (8o!se "o, street&area&s!%!r% et$ ) ermanent Address 95rite o"l. i) di))er e"t tha" :6ddress )or Correspo"de"$e;< )tate: District: Te.sil: Address (8o!se "o, street&area&s!%!r% et$ ) Contact Details Pho"e = 1:/TD Code: 0obile number: Domicile of )tate: Caste: Pho"e No: 'mail !D: Pho"e = ,:/TD Code: District: Te.sil: City&To1n&9illage:

!N Code: City&To1n&9illage:

!N Code: Pho"e No:

+$ "egal Reservation !nformation )ection

,$ )ocial

Category: Ope" & 3eser*ed !f Reserved: /C & /T & DT(6) & NT(>) & NT(C) & NT(D) & O>C & />C )ub-Caste: !f .ysically C.allenged: ?is!all. 4mpaired & /pee$h a"d&or 8eari"g 4mpaired & Orthopedi$ Disorder or 2e"tall. 3etarded Reservation !nformation )ection 9Che$( ( ) +hi$he*er is appli$a%le, +rite "ame o) s!pporti"g do$!m e"t 2em%er o) ProAe$t 6))e$ted -am il. 2em%er o) @arthB!a(e 6))e$ted -amil. 2em%er o) -lood & -ami"e 6))e$ted -amil. 3eside"t o) Tri%al 6r ea Cashmir 2igra"t

atta$hed, i" s e$tio" 6 < o) @#0/er*i$ema" @#0/er*i$ema"&5ard 6$ti*e0/er*i$ ema"&5ard o) 6$ti*e0/er*i$ema" -reedom -ighter&5ard o) -reedom -ighter 5ard o) Primar. Tea$her 5ard o) /e$o"dar. Tea$her Deserted&Di*or$ed&5ido+ed 5ome"

-$ 7uardian !nformation )ection

Occupation of t.e 7uardian: /er*i$e & >!si"ess & Pro)essio" & -armer & Da%orer & 3etired Relations.ip of guardian 1it. applicant: 6""!al 4"$ ome o) the 1!ardia" (3s ): (last )i"a"$ial .ear) .one No$:

lease Turn Over:

Form No$ : 95rite :7@/; i" last $ol!m", agai"st the B!ali).i"g e#ami"at io", o" %asis o) +hi$h .o! are see(i"g t. admissio" to the said $o!rse +rite NO i" )ro"t o) other e#ami"atio"s< lease Note: *3 Details are m andatory in any case "ast College Attended: <ear: Roll No$:

;$ 'ducational Details )ection

Name of '/aminati on Name of %oard &=niversity

Name of )c.ool&College

/td 1E th /td 1,

th

Date of assing #DD&00& < <<<(

'/amination )eat No$ #"ast(

Degree & assing Certific ate No$

7rade & Total 0ar>s Obtained

Ou t of

?ualifying '/aminati on@ #<')&NO(

A$ )elected&Opted apers )ection BCrite paper codes or aper Name only2 in t.e bo/esD <ear& )emester: 1&3&5&G )emester: ,&4&6&H (4) de$ided i" -irst /emester o"l.) 1 1 , , 3 3 4 4 5 5 6 6 G G H H E$ Attac.ed Documents and Certificates )ection
)r$ No$ Name of Document&Certificate th F Passi"g Certi)i$ate o) /td 1E 1 , 3 4 5 6 G H I 1E Passi"g Certi)i$ate o) /td 1, & /tateme"t o) 2ar(s o) /td 1, Dea*i"g Certi)i$ate Certi)i$ate o) Caste +ith Categor. No" Cream. Da.er Certi)i$ate 6))ida*it )or $ ha"ged "ame& 2arriage Certi)i$ate & 1o*t 1azette Domi$ile Certi)i$ate Certi)i$ate )or Ph.si$all. Challe"ged
th th

Original & Attested True Copy 6ttested Tr!e Cop. (2a"dator.) 6ttested Tr!e Cop. Origi"al 6ttested Tr!e Cop. 6ttested Tr!e Cop. Origi"al 6ttested Tr!e Cop. 6ttested Tr!e Cop.

Attac.ed #<es&No(

F$ Ot.er !nformation )ection

2other To"g!e: @mplo.me"t /tat!s: @mplo.ed & '"emplo.ed Do .o! +ish to Aoi" NCC & N// : 7es & No 5o!ld .o! li(e to appl. )or 8ostel: 7es & No 8o%%ies, Pro)i$ie"$. a"d Other 4"terests: 1ames a"d /ports parti$ipatio": De*el (e g $ollege&state&"atio"al&i"ter "atio"al et$ ): Perso"al 4de"ti)i$atio" 2ar(s: 1 ,

G$ Declaration by )tudent
4 here%. de$lare that, 4 ha*e read the r!les related to admissio" a"d the i")ormatio" )illed i" %. me i" this )orm is a$$!rate a"d tr!e to the %est o) m. ("o+ledge 4 +ill %e respo"si%le )or a". dis$repa"$., arisi"g o!t o) the )orm sig"ed %. me a"d 4 !"derta(e that, i" a%se"$e o) a". do$!me"t the )i"al admissio" +ill "ot %e gra"ted a"d&or admissio" +ill sta"d $a"$el ! am a1are of t.e 0a.aras.tra ro.ibition of Ragging Act2 *GGG and ! state t.at ! 1ill abide by all t.e

*3$ Declaration by 7uardian

4 ha*e permitted m. so"&da!ghter&+ard to Aoi" .o!r $ollege The i")ormatio" s!pplied %. him&her is $orre$t to the %est o) m. ("o+ledge 4 ha*e a$B!ai"ted m.sel) +ith the r!les a"d )ees, d!es to m. so"&da!ghter&+ard a"d to see that he&she o%ser*es
lace: Date: **$ For

College&!nstitute =se Only

Remar>s &

)ignature of t.e 7uardian: )ignature and date

Designation Admission Cler> Admission Committee Accountant&Cas.ier Registrar&Office )uperintendent rincipal&Director

articulars & Recommendations

Cash 3e$ei*ed: 3s

3e$eipt No :

Note: /t!de"t 0=)T retai" photo$op. o) $ompletel. )illed i" admissio" )orm (%oth pages) )or )!t!re re)ere"$e 6*aila%le i")ormatio" i" this )orm +ill %e reB!ired to a$ti*ate his&her a$$o!"t o" Digital '"i*ersit. Portal