Application Form

Printed on Course 7/20/2012 12:39:13 PM Bachelor of Commerce GOI Post Matric Scholarship , 2012-2013 Special Backward Class

Application Number Appilcation type Student SSC Details SSC Board Passing Year

APPE0493914M20082012 Renewal Renewal Course Year 1988

Please Paste Passport Size Photograph

MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2008 SSC Seat No E049391 SSC Marks Obtained 68.00

Applicant's Details Applicant Name YOGESH Date of Birth 03-05-1993 EKNATH Gender Male No PATIL Mother's Name JAIBAI

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

Application Date 20-07-2012 Caste Orphan Sonkoli (4-11) No

Maritial Status

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 46000.00 No

Has Applied For Hostel ?

Student Prequalifying Details

Academic Year Institute Course Course Year Percentage Result

2011 - 12

Shahu Shikshan Sanstha ( P ) Matoshree Velbai Devji Hariya College of Arts, Commerce & Science, Shahad Shahu Shikshan Shahu Shikshan

Bachelor of Commerce

0.00

Pass

2010 - 11 2009 - 10

Bachelor of Commerce Bachelor of Commerce

0 0

0.00 0.00

Pass Pass

Institution Details Name of School/College/Institute where Admitted Course Name Subject College Adm.No 360 Is Fees Paid ? Fee Receipt Date Contact Details Residential Number: , MobileNumber: 8097543424, EmailAddress: yogeshpatil863@gmail.com Address For Correspondence Address:- NEAR PRIMARY SCHOOL KHAPARI PADA AT POST ATALI TAL- KALYAN DIST-THANE Location:- AMBIVALI City:- ATALI Pincode:- 421102 Taluka:- Kalyan District:- Thane 1 Of 2 No N.A Shahu Shikshan Sanstha ( P ) Matoshree Velbai Devji Hariya College of Arts, Commerce & Science, Shahad CAP Number 2012-2013 08-06-2012 0.00 GrantTyp Non e Granted Is Admission after Diploma No Joining Date Fee Receipt No. Quota Government Quota 11-06-2012

Bachelor of Commerce Academic Year Admission Dt. Fee Paid Course Year 3

Parent / Guardian Details Parent's name JAIBAI EKNATH PATIL Age Profession 47(yrs) Others

Relation with Applicant Mother 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 568/04 N.A District Issuing Thane Office District Issuing Thane Office Issued in 2012 No Is Mess Service Available? No

NEAR PRIMARY SCHOOL, KHAPARI PADA, AT POST ATALI, TAL- KALYAN, DISTTHANE Annual Income 46000.00 No

Hostel Admission Date Rent Per Month Hostel/Landlord Contact Details N.A

Taluka Issuing Office Scrutiny Committee No University Registration No

Kalyan N.A N.A

Income Certificate 21121219739 No Student Bank Account Details Bank Name Branch Name IFSC Code VIJAYA BANK MOHONE,MAHARASTRA VIJB0005034

Bank Account No MICR Code

503401121000446

400029027

Document Attached Caste Certificate Issued by Competant Officer Income Proof - Income Certificate Issued by Competant Authority Marksheets I-card Size Photo Non Creamy Layer Certificate SSC Mark Sheet Father Death Certificate 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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