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APPLICATION FOR ADMISSION TO FIRST YEAR B.A. | APPLICATION NO.: FYBA_122 | OUTSIDER

PERSONAL INFORMATION

1. Name (as mentioned in SSC mark sheet)

Surname TAMBE

First Name MR. SANDESH

Father's Name SIDDHARTH

Mother's Name SUPRIYA

2. Date of Birth (as mentioned in School Leaving Certificate)

In Figures 1994-04-26

In Words TWENTY SIXTH APRIL NINETEEN NINETY FOUR

Please paste here a

RECENT

photograph

3. Contact Details (Please do not repeat name)

Local Address

27/68, B. D. D. CHAWL, N. M. JOSHI MARG, LOWER PAREL

PIN Code 400013 Landline Mobile 9004364291

Native Place Address

27/68, B. D. D. CHAWL, N. M. JOSHI MARG, LOWER PAREL

PIN Code 400013 Landline Mobile 9004364291

4. Additional DetailsCaste SC Physically Handicapped No Special Category N.A.

Marital Status Unmarried Nationality INDIAN Blood Group N. A.

ACADEMIC INFORMATION

Examination Passed School / College Board / University Month & Yearof Passing

MarksObtained

Out of Percentage Class orGrade

S.S.C/ICSE/CBSE/NIOS MAHARASHTRAHIGHSCHOOL NO. 2 DADAR

MUMBAI 28

MAHARASHTRA 2008-2009 283 650 43.53 B

F.Y.J.C (XI) G. E. I'S NEW HIGH SCHOOL& JR. COLLEGE KALYAN (W)

MAHARASHTRA 2009-2010 366 700 52.28 B

S.Y.J.C (XII) -Arts G. E. I'S NEW HIGH SCHOOL& JR. COLLEGE KALYAN (W)

MAHARASHTRA 2010-2011 286 600 47.67 B

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EXTRA CURRICULAR ACTIVITIES

Event Name Year Level Organizers Place Obtained

1 N.A. N.A. N.A. N.A. N.A.

2 N.A. N.A. N.A. N.A. N.A.

3 N.A. N.A. N.A. N.A. N.A.

DOCUMENT INFORMATION

1. Provisional / Final Eligibility Certificate from HSC Board is obtained and attached / not obtained.

Certificate No. N.A. Dated N.A.

2. Details of School / College Leaving / Transfer Certificate enclosed.

Institution G. E. I'S NEW HIGH SCHOOL & JR. COLLEGE KALYAN (W)

Registration No. 15414 Dated 31-05-2011

PARENT / GUARDIAN INFORMATION

Father / Guardian's Details

Name SIDDHARTH DEVRAM TAMBE Occupation SERVICE Annual Income 140000

Office Address

BMC, E WARD, BYCULLA , MUMBAI

PIN Code 400008 Landline N.A. Mobile N.A.

Mother's Details

Name SUPRIYA S TAMBE Occupation N.A. Annual Income N.A.

Office Address

N.A.

PIN Code N.A. Landline N.A. Mobile N.A.

STATEMENT OF DECLARATIONS

1. I/my ward certify that all the above details are true to the best of my knowledge and belief. If any statement is found to be incorrect, my/my

ward's admission may be cancelled.2. I/my ward agree to conform to the Rules and Regulations at present in force as specified in the prospectus, and those which may be

formulated from time to time. I/my ward further understand that a breach of this undertaking will result in disciplinary action, includingdismissal, against me/my ward.

3. I/my ward agree, if admitted, to be regular in attendance in all lectures, tutorials, practicals, tests and examinations. In case I/my wardam/is found to have less than 75 percent attendance or if my/my ward's progress in the examinations is not satisfactory, I/my ward may notbe allowed to appear for the final examination.

4. I/my ward agree/s that I/my ward may be considered liable to any disciplinary action such as punishment, fine, cancellation of performanceat an examination, cancellation of admission, etc in case I/my ward indulge/s in any of the following: malpractices in an examination(copying, etc), not displaying the Identity Card on person in the College premises, misbehaviour with any staff member, damaging College

property, not paying College fees, and fines within the st ipulated time.

Date Parent / Guardian's Signature Student's Signature

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6/13/2011