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Registration Form



Sahajeevan Shikshan Sansstha's
Shrimati indira mahadev beharay college of arts,
Shriman chandulal sheth college of commerce and
shrimati shobhnatai chandulal sheth college of science,
khed-415709; Dist.ratnagiti naac reaccredited with 'B' grade

ADMISSION FORM : 2017-18

Course admitted to:

I.D. No:

Roll No:

Form No:

Admission Date:

Kindly read important notes before filling-in-form :-

Use blank ink pen to fill in the form and do not overwrite.

Fill in all fields in CAPITAL letters only.

Strike-off whichever is NOT applicable.Eg.if you are a male/female

course applied for(e.g I.T./B.M.S./C.S.):

course part of semester applied for(e.g |/||/|||..):

Student should sign strictly inside this box only with black ink.

1:Personal information section: Last name First name Middle name

Name Of the student:
(in case of changed name,write current name)

Name Of the student:
(in Devnagari (Marathi) script)

Name Of the student:
(As printed on std.10th passing certificate)

Father/Husband's name:

Mother's name:

Previous name of student:
(in case of changed name)

Reason for name change:
willinglyAfter marriage
Marital status:UnmarriedMarriedDivorcedWidowedDesserted
Date of Birth(DD/MM/YY): Gender:
MaleFemale
Place of Birth: Blood Group(with Rh):
Religion: Citizen of(Country Name):
Student's location category:
RuralUrbanTribal
Address of correspondence:
State: District: Tehsil: City/Town/Village:
Address:(House No,street/Area etc.) pincode:
Permant Address:(Write only if different that 'Address of correspondence'.)
State: District: Tehsil: City/Town/Village:
Address:(House No,street/Area etc.) pincode:
Contact Details:
Phone#1:Area/STD code() Phone#2:Area/STD code()
Mobile no: E-mail ID:
Legal reservation information section:
Domicile of state: Category:
OpenReserved
If reserved:
SCSTDT(A)NT(B)NT(C)NT(D)OBCSBC
caste: sub-caste: If Physically challenged:
Visually impairedspeech and or hearing impairedOrthopedic disorder or mentally retarted
Social reservation information section[Please tick whichever is applicable,write name of supporting document attachment,in section 6]:
Ex-serviceman/ward of Ex-serviceman Member of project affected family
Active-serviceman/ward of Active-serviceman Member of earthquake affected family
Freedom fighter/ward of Freedom fighter Member of Flood/Famine affected family
ward of Primary Teacher Member of Tribal area
ward of Secondary Teacher Resident of Tribal area
Deserted/Divorcd/widowed women
Guardian/information section:
Occupation of guardian:service/business/profession/farmer/labour/retired Annual income of the guardian(last financial year) (RS:)
Relationship of guardian with applicant: Phone no: