Application Form

Printed on Course 10/9/2013 4:30:15 PM M. Tech. Information GOI Post Matric Scholarship , 2013-2014 Scheduled Caste

Application Number Appilcation type Student SSC Details SSC Board Passing Year

APPH0494676M20052013 Renewal Renewal Course Year 2012

Please Paste Passport Size Photograph

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2005 SSC Seat No H049467 SSC Marks Obtained 65.73

Applicant's Details Applicant Name VIVEK Date of Birth 02-09-1989 DHARMDAS Gender Maritial Status MOHOD Male No Mother's Name BEBITAI

Is Resident of Maharashtra Maharashtra Caste Category Sub Caste Scheduled Caste

Application Date 04-09-2013 Caste Orphan Mahar (37) No

Is Disabled Applicant's Annual Income

No 80000.00

Disability Type

N.A.

Is Applicant Salaried ? Yes Is Staying at Hostel ? Yes

Total Annual Income 130000.00 No

Has Applied For Hostel ?

Student Prequalifying Details

Academic Year Institute Course Course Year Percentage Result

2012 - 13 2011 - 12 2010 - 11

SGGS No Institute attended R.G.P.M,BHOPAL

M.Tech. Information Course not Attended Bachelor of Engineering (Computer Science)

2 0 4

6.15 0.00 65.00

Pass Fail Pass

Institution Details Name of School/College/Institute where Admitted Course Name Course Year EID Number Subject College Adm.No 2012MIT012 Is Fees Paid ? Fee Receipt Date Contact Details No N.A Shri Guru Govind Singhji Institute of Engg.& Technology Vishnupuri

M. Tech. Information 2 N.A Academic Year Admission Dt. Fee Paid GrantType 2013-2014 29-07-2013 0.00 Granted Is Admission after No Diploma Joining Date 04-07-2013 Fee Receipt No. Quota Government Quota CAP Number N.A UID Number N.A

Residential Number: N.A, MobileNumber: 9028782035, EmailAddress: vivekmohod0209@gmail.com Address For Correspondence

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Parent / Guardian Details Parent's name DHARMDA S Relation with Applicant Father Parmanent Address Is Father Alive Hostel Information Name of Landlord / Hostel Hostel Type SHRI HIRAMAN MARIBA BHOLE Is Mess Service Available? No Hostel Admission Date Rent Per Month Hostel/Landlord Contact Details 29-07-2013 0.00 9860397544 Yes Annual Income 130000.00 MOHOD Age Profession (yrs) Teacher

Other

Hostel/ Landlord LABOR COLONY NANDED. Address Is Studying in night school Document Details Caste Certificate No Caste Validity Certificate No 178/3/2011-2012 26598 District Issuing Amravati Office District Issuing Amravati Office Issued in 2013 No

Taluka Issuing Office Scrutiny Committee No University Registration No

Amravati MRC81\Amravati \17813 N.A

Income Certificate 81/2013-14 No Student Bank Account Details Bank Name Branch Name IFSC Code STATE BANK OF INDIA

Bank Account No MICR Code

30499062748

AGRI COMM BR AMRAVATI SBIN0014890 NON-MICR

Document Attached Caste Certificate Issued by Competant Officer Income Proof - Form 16 Income Proof Income Certificate Issued by Competant Authority Marksheets I-card Size Photo Caste Validity Certificate SSC Mark Sheet 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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