Application Form

Printed on Course 9/9/2013 9:07:53 PM Bachelor of Engineering GOI Post Matric Scholarship , 2013-2014 Other Backward Class

Application Number Appilcation type Student SSC Details SSC Board Passing Year

APPE0650104M20102013 Renewal Renewal Course Year N.A

Please Paste Passport Size Photograph

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2010 SSC Seat No E065010 SSC Marks Obtained 82.00

Applicant's Details Applicant Name RAHUL Date of Birth 05-01-1995 SHIVAJI Gender Maritial Status GADEKAR Male No Mother's Name RADHIKA

Is Resident of Maharashtra Maharashtra Caste Category Sub Caste Other Backward Class

Application Date 25-08-2013 Caste Orphan

nhavi (Salmani, Hajam) (108) No Is Disabled Applicant's Annual Income No 0.00

Disability Type

N.A.

Is Applicant Salaried ? NO Is Staying at Hostel ? No

Total Annual Income 60000.00 No

Has Applied For Hostel ?

Student Prequalifying Details

Academic Year Institute Course Course Year Percentage Result

2012 - 13 2011 - 12 2010 - 11

GOVERNMENT POLYTECHNIC THANE GOVERNMENT POLYTECHNIC THANE GOVERNMENT POLYTECHNIC THANE

Diploma in Engineering (Computer) Diploma in Engineering (Computer) Diploma in Engineering (Computer)

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68.52 59.88 60.25

Pass Pass Pass

Institution Details Name of School/College/Institute where Admitted Course Name Course Year EID Number Subject College Adm.No 69 Is Fees Paid ? Fee Receipt Date Contact Details No N.A Academic Year Admission Dt. Fee Paid GrantType 2013-2014 18-08-2013 0.00 Non Granted Is Admission after Yes Diploma Joining Date 19-08-2013 Fee Receipt No. Quota Government Quota G.V. Acharya Institute of Eng. And Tecnology, karjat

Bachelor of Engineering 2 CAP Number DSE13197872 UID Number 322619177200

Residential Number: , MobileNumber: 7208737237, EmailAddress: gadekar95@gmail.com

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Address For Correspondence Address:- JYOTI COLONY Location:- LAL CHAKKI ROAD City:- Ulhasnagar Pincode:- 421004 Taluka:- Ulhasnagar District:- Thane Parent / Guardian Details Parent's name SHIVAJI KASHINATH GADEKAR Age Profession 46(yrs) Service

Relation with Applicant Father Parmanent Address Is Father Alive Hostel Information Name of Landlord / Hostel Hostel Type Hostel/ Landlord Address Is Studying in night school Document Details Caste Certificate No Caste Validity Certificate No 18/09 155196 District Issuing Thane Office District Issuing Thane Office Issued in 2013 No Is Mess Service Available? No

JYOTI COLONY Location:- LAL CHAKKI ROAD City:- Ulhasnagar Pincode:- 421004 Taluka:- Ulhasnagar District:- Thane Annual Income 60000.00 Yes

Hostel Admission Date Rent Per Month Hostel/Landlord Contact Details 0.00

Taluka Issuing Office Scrutiny Committee No University Registration No

Ulhasnagar THANE/ENGG/72/ CVN N.A

Income Certificate 421/2013 No Student Bank Account Details Bank Name Branch Name IFSC Code

BANK OF MAHARASHTRA ULHASNAGAR IV MAHB0000347

Bank Account No MICR Code

60022673510

NOT AVAILABLE

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 Creamy Layer 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 _______________________

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