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Application Form Please Paste Pasport Size Photograph Application Number Appilcation type Student SSC Details APP5533111200000030 New Renewal Course Year N. A SSC Board Passing Year Applicant’s Details MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2009 SSC Seat No A276644 SSC Marks Obtained 75. 69 Applicant Name Date of Birth AKASH first name RAJU middle name PANTAVANE last name Mother’s Name Is Resident of Maharashtra Application Date MANDA Maharashtra 07-02-1994 Gender Male Academic Year Caste Category Caste Orphan Is Applicant Salaried ? Maritial Status 011-2012 Scheduled Caste Mahar (37) No No Is Disabled Applicant’s Annual Income Is Staying at Hostel ? Sub Caste No 0. 00 02-10-2011 Disability Type N. A. 50000. 00 Total Annual Income Has Applied For Hostel ? No No No Student Prequalifying Details Last attended School/College/Institute Last Exam Passed Passed Institution Details Bahvans Junior College Last Exam Passed Year 2011 Last Exam Marks 44 HSC Yes Name of School/College/Institute where Admitted Course Name Subject College Admission Number Is Fees Paid ? Fee Receipt Date Ramrao Adik Education Society’s Ramrao Adik Institute of Technology,Nerul, Navi Mumbai-400706

Bachelor of Engineering (ENTC) ENTC 11ET1103 Is Admission after Diploma Date Of Admission Fee Paid Course Year No 24-08-2011 Academic Year Joining Date 2011-2012 26-08-2011 No 0. 00 1 Fee Receipt No. Quota Government Quota Contact Details Residential Number: N. A, MobileNumber: 9833464211, EmailAddress: N. A Address For Correspondence Address:- Shree Ganesh Society, Sunder Nagar, Tunga Village, Saki Vihar Road, Powai – 400072 Location:- Mumbai City:- Sakinaka Pincode:- 400072 Taluka:- Mumbai(Suburban) District:- Mumbai(Suburban) Parent / Guardian Details Parent’s name RAJU first name Wamanrao middle name PANTAVANE last name

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Relation with Applicant Parmanent Address Father Parent Age 47 (yrs) Profession Others Shree Ganesh Society, Sunder Nagar, Tunga Village, Saki Vihar Road, Powai – 400072 Parents Annual Income 50000. 00 Hostel Information Name of Landlord / Hostel Hostel Type N. A Hostel Admission Date Is Mess Service Available? No Rent Per Month N. A N. A Hostel/ Landlord Address N. A Hostel/Landlord Contact Details N. A Is Studying in night school Document Details No Caste Certificate No Caste Validity Certificate No Income Certificate No University Registration No G5559/1999 District Issuing Office District Issuing Office Issued in Mumbai(Suburban)

Taluka Issuing Office Scrutiny Committee No Mumbai(Suburban) 21228 Mumbai(Suburban) 6479 2011 Student Bank Account Details Bank Name Branch Name CORPORATION BANK MUMBAI-VERSOA Bank Account No SB01092664 Document Attached Caste Certificate Issued by Competant Officer Income Proof – Income Certificate Issued by Competant Authority Marksheets I-card Size Photo Caste Validity Certificate District Transfer Certificate Declaration The information furnished by me is complete and correct. I bear the complete responsibility for all the above information. Applicant’s Signature Applicant Parent’s Signature Principal’s Signature

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