To, Form Number:PUN06253

The Divisional Secretary,

Maharashtra State Board of Secondary And Higher Secondary Education,
PUNE Divisional Board.
Sir,
I request you to issue enrollment Certificate as a Private Candidate at the H.S.C Examination(Std.XII)
to be held in March 2018 and submit the following particulars for your information.

Full Name SIDDHESH CHINTAMANI SHIPURKAR

Mother's Name SHUBHANGI
Residential Address B13, BHOSALE PARK,
OPPOSITE VAIBHAV THEATRE,
HADAPSAR,PUNE
Residential PinCode 411028
District PUNE
State MAHARASHTRA
Student Email ID CHITRA.DINGANE@GMAIL.COM
Mobile Number 9422043048
Adhar Number 766257189569
Gender Male
Birth Date 11/29/1998
Birth Date In Words November Twenty Ninth One Thousand
Nine Hundred Ninety Eight
Birth Taluka MHASALE
Birth City MHASALE
Birth District RAIGAD
Month of Passing SSC Exam March
Year of Passing SSC Exam 2016
Name of the examination Board or PUNE BOARD
University
Date of Leaving the last Attended 05/31/2016
Secondary School
Date of Leaving the last Attended Junior 07/17/2017
College
I would like to appear in Stream Commerce
Name of Last Attended Secondary SADHANA VIDYALAY
School
village/town of Last Attended School HADAPSAR
District of Last Attended School PUNE
State of Last Attended School MAHARASHTRA
Udise Code of Last Attended School 27251700111
INDEX number of Last Attended School 1115010
Name of Last Attended junior College JAYAWANTRAO SAWANT
POLYTECHNIC
village/town of Last Attended Junior HADARPSAR
College
District of Last Attended Junior College PUNE
State of Last Attended Junior College MAHARASHTRA
Udise Code of Last Attended Junior -
College
Index Number Of Last Attended Junior -
College
The month & Year of passing 1st year of NA NA
junior college exam
Stream of passing 1st year of junior NA
college exam
Status 1st year of junior college exam NA
Debarred from appearing at any of the no
examination
 Undertaking to be given by the candidate

i) I,SIDDHESH CHINTAMANI SHIPURKAR have not passed the H.S.C

Examination conducted by the Maharashtra State Board of Secondary and
Higher Secondary Education or any other equivalent higher examination of
any statutory Board or University.I know and understand that I have filled up
Form No.17 through my junior college only to get permission from H.S.C
Board to appear as a private candidate for H.S.C Exam.Further I assure that I
will take all the information about the permission to be granted to me and
submission of H.S.c examination application form in time through my junior
College. If I failed to do so,I will not make any complaint in this matter.

ii) I hereby declare that information given overleaf is true and correct

iii)I have carefully read the Instructions to Private Candidate enclosed

herewith.

iv) I am Prepared to select only such subjects as are allowed to be offered for
the H.S.C.

v)Exam by Private Candidates.I am aware that I am not eligible to offer the

Vocational and Bifocal Subjects.

Place:PUNE Signature of the Applicant

IP:115.96.171.133
Date:8/9/2017 (SIDDHESH CHINTAMANI
SHIPURKAR)

Note: Kindly submit application form to college

R.R.SHINDE JUNIOR COLLEGE, HADAPSAR, PUNE-411 028

Along with original documents and processing fees Rs.600 before 21st August 2017.

You have to submit following Documents:

Junior college Leaving Certificate.
 RECEIPT(For Office Use)

EC NO:PUN06253 Date:8/9/2017

From, SIDDHESH CHINTAMANI SHIPURKAR Received Rs.SIX

HUNDRED only.For the Enrollment & Processing as a private Candidate for
HSC Examination.

Cashier

RECEIPT(For College Use)

EC NO:PUN06253 Date:8/9/2017

From, SIDDHESH CHINTAMANI SHIPURKAR Received Rs.SIX

HUNDRED only.For the Enrollment & Processing as a private Candidate for
HSC Examination.

Cashier

RECEIPT(For Student)

EC NO:PUN06253 Date:8/9/2017

From, SIDDHESH CHINTAMANI SHIPURKAR Received Rs.SIX

HUNDRED only.For the Enrollment & Processing as a private Candidate for
HSC Examination.

Cashier