NAGAR YUWAK SHIKSHAN SANSTHAS

YESHWANTRAO CHAVAN COLLEGE OF ENGINEERING

(An Autonomous Institution affiliated to Rashtrasant Tukadoji Maharaj, Nagpur University, Nagpur)

HINGNA ROAD, WANADONGRI, NAGPUR - 441 110

College code:

Admission Application Form (AAF)

for First Year B. E. Session 2016-2017
under Institute Level Quota
College Id : EN4167
Form No.:

60

For college use only

Please paste a
passport size
Photograph here,
Do NOT staple

Course admitted to : B. E. in
Admission date

Kindly read important notes before filling in form :

1. Use Black /Blue Ink to fill in the form and Do NOT overwrite
2. Fill in all fields in CAPITAL letters only.
3. Strike off whichever is NOT applicable.

(Signature)
Student should sign strictly inside this
box only with Black /Blue Ink.

1. Personal Information
Last name

First name

Middle name

Name of the student

(In case of changed name, write current name)

Name of the student

(In Marathi / Hindi Only)

Name of the Student as printed

on SSC passing Certificate

Fathers / Husbands Name

Mothers Name
Previous name of the student
(in case of changed name)

Reason for name change : Willingly / After Marriage

Marital Status : Unmarried / Married

Date of Birth (DD/MM/YYYY) :

Gender : Male / Female

Place of Birth :

Religion :

Blood Group (with RH):

Citizen of (Country Name) :

Address for Correspondence: ( Permanent )

Address (House no. street / area etc.)

Village/Tehsil :

City:

District:

State:

PIN Code:

Address for Correspondence: ( Local )

Address (House no. street / area etc.)

Village/Tehsil :

City:

District:

State:
Contact Details :
Phone (Area / STD Code)
Mobile Number :
Email ID :

PIN Code:
Student

Parent/Guardian

2. Legal Reservation information

Domicile of State :

Category : Open / Reserved

If Reserved : SC / ST / DT(A) / NT(B) / NT ( C ) / NT (D) / OBC / SBC

Caste :

Sub- Caste :

If Physically Challenged : Visually Impaired / Speech and / or

hearing Impaired / Orthopedic Disorder or mentally Retarded

3. Educational Details [ Write Yes in last column, against the qualifying examination, on basis of which you are seeking admission to
the said course write NO in front of other examinations]

Name of
Examination

Name of Board /
University

Date of
Passing

Name of School /
College

(DD / MM
/YYYY)

Examinat
ion Seat
no. (Last)

Degree /
Passing
Certificate
No.

Grade /
Total
Marks
Obtained

Out of

Qualifying
Examination ?
(Yes / No )

Std 10th

Std 12th

Std. 12th PCM details:

SUBJECT

ENGLISH

MATHS

PHYSICS

CHEMISTRY

Biology /
BioTechnology /
Technical Vocational

MARKS OBTAINED
OUT OF
Entrance Exam details:
SUBJECT

ROLL NO.

PHYSICS

CHEMISTRY

MATHS

Total Marks

MHT-CET 2016
JEE (MAIN)-2016
CAP Registration Details:
CAP Application ID
Candidature Type ( MS or OMS )
Merit Number ( Based on MHT-CET 16 Score ) *
Merit Number ( Based on JEE (Main) 2016Score ) *
*(attach documentary proof for Merit number)

4. Attached Documents and Certificates

Sr.
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Name of Document / Certificate

MHT-CET 2016 / JEE (Main) 2016 Score Card
Statement of Marks of Std 10th (Marksheet)
Passing Certificate of Std 10th
Statement of Marks of Std 12th (Marksheet)
Leaving Certificate / Transfer Certificate
Nationality Certificate
Domicile Certificate
if applicable :Certificate Caste with Category
Caste Validity Certificate
Non Creamy Layer Certificate (Valid upto 31.03.2017)
Migration Certificate ( other than M.S. Board)
Eligibility Certificate (Other than M.S. Board, from RTM Nagpur University)
Gap Certificate
Certificate for Physically Challenged
Parent Income Certificate (if Applicable)
Affidavit for changed name / Marriage Certificate / Govt. Gazette

Original /
Attested True Copy

Attached
( Yes / No )

5. Parents Information
Fathers Name :

Mobile No. :

e-mail :
Occupation of the Father: Service / Business /

Annual Income of the Father (Rs.):

Profession / Farmer / Labored / Retired

Designation

Name of Employer / Company

Mothers Name :

Mobile No. :

e-mail :
Occupation of the Mother: Service / Business /

Annual Income of the Mother (Rs.):

Profession / Farmer / Labored / Retired

Total Annual Income (Rs.) :

Designation

Name of Employer / Company

6. Other Information
Employment Status :
Employed / Unemployed

Mother Tongue :
Would you like to apply for Hostel

Do you wish to join NCC / NSS :

Yes / No

: Yes / No

Hobbies, Proficiency and Other Interests :

Games and Sport Participants
Level (e.g. college / state / national / international etc.):

7. Declaration by Student
I hereby declare that, I have read the rules related to admission and the information filled in by me in this form is
accurate and true to the best of my knowledge. I will be responsible for any discrepancy, arising out of the form
signed by me and undertake that, in absence of any document, the final admission will not be granted and / or
admission will stand cancel.
I am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that I will abide by all the rules and regulation of the said Act.

Place :
Date

:
Signature of the student:

8. Declaration by Guardian
I have permitted my son / daughter / ward to join your college. The information supplied by him / her is correct to the
best of my knowledge. I have acquainted myself with the rules and fees, dues to my son / daughter / ward and to see
the he / she observes.
I am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that my ward will abide by all the rules and regulation of the
said Act.

Place :
Date

:
Signature of the Guardian:
For College / Institute Use Only
Designation

Remarks / Particulars /
Recommendations

Admission Clerk
Admission Committee
Accountant / Cashier
Registrar / Office Superintendent
Principal / Director / Authorised Signatory

Cash Received : Rs.

Receipt No. :

Signature and date