Admission Form for Session: 2024-2025 | Form No: P15022

Application Form for Admission to class FYBA GB Medium Select Medium

(For Office Use Only)

Registration No. Date Of Admission

Admission Granted Signature Admission Granted Signature P15022
Principal Admission Record Clerk
Admission Committee Member Cashier Admission Fee (In Rs.) Cash Receipt No.

To
The Principal,
Bhiwandi Nizampur Nagarpalika SR College (Arts,Commerce,Science) photograph
Bnn College Dhamankar Naka kamatghar road Bhiwandi dist Thane Maharashtra 421302

Respected Sir/Madam,

I, Harsh Ganesh Naik hereby apply for the admission to the above mentioned class. If admitted to the college, I promise to abide by the rules & regulations of the
college and also abide by the terms and conditions of admission as given in the college prospectus and payment of the College Fees. My attendance will be above 75% in
college. I know that there will be no Social Gathering and no election of student union in the college and I fully agree to this.

Date: 24-06-2024 Signature of the Applicant

1 Personal Information

Payment Category: Upi Miss/Mr: Mr

First Name: Harsh Middle Name: Ganesh

Last Name: Naik Date Of Birth: 26-05-2004

BirthPlace: kalyan Gender: Male

Mothertongue: marathi Nationality: INDIAN

Father Name: GANESH Mother Name : MANISHA

 Admission Form for Session: 2024-2025 | Form No: P15022

DNYANESHWARI NIWAS HOUSE NO 755

Local Address: Local District: THANE
TEMGHAR PADA BHIWANDI
Local Pin Code: 421302 Local State: MAHARASHTRA

DNYANESHWARI NIWAS HOUSE NO 755

Local Country: INDIAN Permanent Address:
TEMGHAR PADA BHIWANDI

Permanent District: THANE Permanent Pin Code: 421302

Permanent State: MAHARASHTRA Permanent Country: INDIAN

Contact Number 1 For SMS: 7350570303 Email ID: [email protected]

Marital Status: UnMarried Is Student NRI/Foreign National: No

Blood Group: B-

2 Guardian Information

Occupation: FARMER Income: 90000

3 Legal Reservation Information

Category Type: Reserved Category: OBC

Caste: Agri Is Specially Abled?: No

4 Educational Details

SSC Board Examination: SSC BOARD HSC Board Examination: HSC BOARD

SSC Board / University: MUMBAI UNIVERSITY HSC Board / University: MUMBAI UNIVERSITY

SSC Exam Seat No: A103165 HSC Exam Seat No:

SSC Mark Obtained: 296 HSC Mark Obtained: 271

SSC Out Of: 500 HSC Out Of: 600

SSC CGPA: 00 HSC CGPA : 00

SSC Percentage: 59.20 HSC Percentage : 45.16

Documents

Certificate Of Caste With Cate: Marksheet: SEM-I Marksheet: SEM-II Marksheet: SEM-III Marksheet: SEM-IV Marksheet:

Undertaking by S.C. /S.T./V.J.N.T./P.T.C./O.B.C. Other Concession Holders only:

 Admission Form for Session: 2024-2025 | Form No: P15022

I here by declare that I shall attend classes regularly and complete minimum attendance necessary to getting the concession in fees or scholarship as per Government rules.
In case, I remain absent continuously for one month without permission from the Principal, I know that my name will be removed from the roll of students of the college.
If I do not complete the required attendance in the class. I know that my scholarship or concession in fees will be stopped and I shall be fully responsible for payment of full fess to the
college.

Signature of student Uploaded Signature of Student Signature of FATHER OR GUARDIAN

DECLARATION & UNDERTAKING BY THE FATHER OR GUARDIAN :

I hereby declare that the applicant Is my daughter / ward. The information given above is correct.
I further declare that my daughter / ward had read prospectus carefully and will abide by all the rules & regulation of the college given in the college prospectus. She will also restrain from
taking part in any non-academic activities: like agitational violent demonstrations of any kind within the premises of the college.
In case she found guilty of creation indiscipline in the college campus / She will be expelled, from the college. I further undertake to pay all the dues of the college in time. I know that my
daughter /ward will not be allowed to appear for Board / University Examination if she does not attend 75% of the lectures delivered in each subjects. I also know that there will be no Elections
for students Union and no Social Gathering or College Day will be celebrate in the college and I fully agree to this.

Date: 24-06-2024 Signature of Father and Guardian