Application Form

Printed on

9/30/2015 11:42:15 AM

Course

Master of Business Administration

GOI Post Matric Scholarship , 2015-2016

Application Number

APPH0961726M20082015

Application type

New

Renewal Course Year

Other Backward Class

N.A

Student SSC Details

SSC Board

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION

Passing Year

2008

SSC Seat No

H096172

SSC Marks Obtained

79.38

Applicant's Details
ANANT

Mother's Name

Applicant Name

NITIN

PATIL

Date of Birth

04-08-1991

Gender

Male

Is Resident of Maharashtra

Application Date

29-09-2015

Marital Status

No

Caste Category

Caste

Kunbi (83)

Sub Caste

Orphan

No

Is Disabled

Is Applicant Salaried ?

NO

Applicant's Annual Income

No

Maharashtra

Other Backward Class

Leva Patidar (83)

Disability Type
0.00

MINAKSHI

N.A.

Total Annual Income

45000.00

Student Prequalifying Details

Academic Year

Institute

Course

Course Year

Percentage

Result

2014 - 15

Smt.G.G.Khadse college

Bachelor of Science (General)

57.80

Pass

2013 - 14

Smt. G. G. Khadse Science & Arts Bachelor of Science (General)

College, Muktainagar, Dist.Jalgaon

51.70

Pass

0.00

Pass

2012 - 13

Course not Attended

Institution Details
Name of School/College/Institute where Admitted
Course Name
UID Number

Padmashree Dr.D.y.Patil Pratishthan"s Dr.D.Y.Patil Institute of Engineering &

Technology, Pimpri, Pune - 411018

Master of Business Administration

757586892471

Is Admission after Diploma?

No

Course Year

EID Number
Subject

N.A

College Adm.No

MB15138

Quota

Is Fees Paid ?

No

Fee Paid

0.00

GrantType

Non Granted

Fee Receipt Date

N.A

Government Quota

CAP Number

MB15100385

Joining Date

29-06-2015

Fee Receipt No.

Contact Details
Residential Number: 9850510665, MobileNumber: 7709405975, EmailAddress:
Address For Correspondence
Address:- Location:- City:- Malkapur Pincode:- 443101 Taluka:- Malkapur District:- Buldana

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Parent / Guardian Details

Parent's name

ANANT

WAMAN

PATIL

Relation with Applicant

Father

Parmanent Address

Location:- City:- Dharangaon Pincode:- 443101 Taluka:- Malkapur District:- Buldana

Is Father Alive?

Yes

Age

55(yrs)

Profession

Annual Income

Farmer

45000.00

Hostel Information
Is Staying at Hostel ?

No

Has Applied For Hostel ?

No

Is Studying in night school?

Name of Landlord / Hostel

No

Hostel Admission Date

Hostel Type

Is Mess Service Available?

No

Rent Per Month

0.00

Hostel/ Landlord Address

Hostel/Landlord Contact Details
Document Details
Caste Certificate No

MRC81/4340/2014

District Issuing
Office

Buldana

Taluka Issuing
Office

Malkapur

Caste Validity
Certificate No

18630

District Issuing
Office

Akola

Scrutiny
Committee No

Income Certificate No

39790001864

Issued in

2015

University
Registration No

NA

Student Bank Account Details

Bank Name

CENTRAL BANK OF INDIA

Branch Name

EDLABAD

Bank Account No
IFSC Code

CBIN0281046

2900077908

MICR Code NON-MICR

Document Attached
Caste Certificate Issued by Competant Officer
Income Proof Income Certificate Issued by Competant Authority
Marksheets
I-card Size Photo
Education Gap Certificate
SSC Mark Sheet
UID document xerox
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

_______________________

NOTE: PLEASE SUBMIT THE HARD COPY (PRINTOUT) OF THE APPLICATION FORM TO THE COLLEGE WITHIN 30 DAYS.

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