Application Form

Please Paste Pasport Size Photograph

Application Number Appilcation type

Student SSC Details

APP13297111200000001 New Renewal Course Year N.A

SSC Board Passing Year

Applicant's Details

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2008 SSC Seat No D017940 SSC Marks Obtained 82.61

Applicant Name Date of Birth

SAMADHAN
first name

DHONDIRAM
middle name

KHATAL
last name

Mother's Name Is Resident of Maharashtra Application Date

PARVATI Maharashtra

05-06-1993

Gender

Male

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

2011-2012 Vimukta Jat Nomadic Tribes Dhangar (29) No No Is Disabled Applicant's Annual Income Is Staying at Hostel ? Sub Caste No 0.00

09-10-2011

Disability Type

N.A. 261562.00

Total Annual Income Has Applied For Hostel ?

No

No

No

Student Prequalifying Details

Last attended School/College/Institute Last Exam Passed Passed

Institution Details

K J Mehta High-School & E Y Phadol Jr College Nashik,Nashik -422101 Last Exam Passed Year 2010 Last Exam Marks 74

HSC Yes

Name of School/College/Institute where Admitted Course Name Subject College Admission Number Is Fees Paid ? Fee Receipt Date 42

Govt. Dental College & Hospital, Mumbai 400 001.

Bachelor of Dental Surgery Is Admission after Diploma Date Of Admission Fee Paid Course Year No 26-07-2011 Academic Year Joining Date 2011-2012 01-08-2011

No

0.00 1

Fee Receipt No. Quota Government Quota

Contact Details

Residential Number: N.A, MobileNumber: 8652308092, EmailAddress: ksamadhand@gmail.com

Address For Correspondence

Address:- Sector-7, room No-505, block no-20A, type-2, C G S colony, S M Plot Location:- Mumbai
Parent / Guardian Details

City:- Antop Hill

Pincode:- 400037

Taluka:- Mumbai

District:-

Parent's name

DHONDIRAM
first name

BAPU
middle name

KHATAL
last name

Relation with Applicant Parmanent Address

Father

Parent Age

50

(yrs)

Profession

Service

A/P -Banpuri Dist-Sangli Tal-Atpadi Maharashtra-415306

Parents Annual Income

261562.00

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

MAG/SR/25/2003

District Issuing Office District Issuing Office Issued in

Sangli

Taluka Issuing Office Scrutiny Committee No

Atpadi

53582

Nashik

MAG/SR/27/2011

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 Education Gap 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