Form Fee: 50 Application for Eligibility Roll No/Admission No

(For Under Graduate Courses Only) (for office use)

________________________________________________________________________
I wish to apply or the Eligibility for academic year: 2019 - Date : 16/07/2019
2020

1. Name of the Course to which application is sought: FY BSc(General)

Year:- 1st / 2nd / 3rd / 4th / 5th
2. Name in full of the Applicant:- TOMBE SANTO OCHAN MODI
3. Mother's Name:- ROSE
4. Nationality:- Sudanese
5. Type:- Maharashtrian
6. Gender:- Male
7. Date of Birth:- Apr 04,1999
8. Reserved Category:- OPEN
(If you belong to any Reserved Categories, attach certificate of Competent Authority in support of it.)
Do you belong to the creamy layer of NT(C), NT(D) and No
OBC?
(If you do not belong to the creamy layer, submit a certificate of Competent Authority in support of it.)
9. Are you a physically handicap? No

Particulars of the H.S.C. Examination

1.Have you passed Exam from Maharashtra board?Yes / No
if No please specify Name of Board :-
2.Name of the school/Jr. College/College :- COMBONI SECONDARY SCHOOL
Seat No. Month & Year of Percentage Class/Grade
Passing
0101292 2019 85.4 percent

Please specify Educational gap Details if any ( to be filled by candidate ):-

Last Examination Seat No. Month & Year of Percentage Class/Grade
Name Passing.

10. Are you Belong to the Minority?No/Yes(if yes please specify type which has given below ) .
Linguistic: _____ Religious: _____

Signature of Candidate
___________________________________________________________________________
Copies of Following attested certificates are annexed to application form
1. Statement of Marks of the qualifying 4. Domicile Certificate
examination
2. Education Gap certificate 5. Cast certificate (For reserved category
candidates)
3. Affidavit for change in name 6. Cast validity certificate (For reserved category
candidates)
7. Transfer Certificate