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

college code : RT-08


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Course admitted to: *

I.D. No:

Roll No:

Form No:

Admission Date:

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

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 I/II/III..):

Student Sign

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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:
(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:
Male Female *
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:
Open Reserved
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: *
5.Educational Detail Selection[write 'yes' in last column,against the colifying examination,on basis of which you are seeking admission to the said course 'no' in front of other examinations]please note:10th details are mandatory in any case

Last college attended:

Year:

Roll No:

Name of examination Name of Board/University Name of school/college Date of passing (DD/MM/YYYY) Examination seat No(last) Degree/passing certificate No Grade/Total mark obtained Out of Qualifying Examination?(Yes/No)
YesNo
std 12th YesNo
YesNo
YesNo

Selected/opted paper section[write paper codes or paper name only in the boxes]

Year/Semester:1/3/5/7 semester:2/4/6/8(if decided in semester only)
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8

Attached Documents and Certificates section:

Sr No Name of Document/Certificate Original/Attested True Copy Attested True(yes/no)
1. Passing certificate of Std.10th Attested True Copy(Mandatory) YesNo
2. Passing certificate of Std.12th/Statement of Marksof std.12th Attested True Copy YesNo
3. Leaving Certificate Original YesNo
4. Certificate of cast with category Attested True Copy YesNo
5. Non Creamy layer certificate Attested True Copy YesNo
6. Affidavit with changed name/marriage certificate/Govt.Gazette Original YesNo
7. Domicile Certificate Attested True Copy YesNo
8. Certificate of physically challenged Attested True Copy YesNo

Other information section:

Mother Tongue: Employment status:
EmployedUnemployed
Do you wish to join NCC/NSS:
YesNo
Would you like to apply for Hostel:YesNo
Hobbies,Proficiency and other Interests:
Game and other participation?
level(e.g.College/State/National/International):
Personal identification Marks: 1: 2:
Declaration of Student:
I hereby declare that,I have read the rules related to the admission and the information filled in by me in this form is accurate and true to the best of my knowledge. I will be responcible for any discrepacy,arising out of the form signed by me and I undertake that,In absency of any documents the final admission will not be granted and /or admission will stand cancel.
I am aware of the Maharashtra prohibition of Ragging Act,1999 and I state that I will abide by all the rules and regulation of the said Act

Place:Khed.

Date:

Signature of Student:

Declaration of Guardian:
I have permitted my son/daughter/ward to join your college.The information supplied by him/her is correct to the best of my knowledge I have acquainted myself with the rules and fees due to my son/daughter/ward to see he/she observes.

Place:Khed.

Date:

Signature of Guardian:

For College/Institute Use Only:
Designation Remarks/Particulars/Recommendations Signature and date
Admission clerk
Admission Committee
Account/Cashier Cash received Rs.
Registrar/office supretendent
Principal/Director

Note:Student MUST retain photocopy of completely filled in admission form(both page) for future reference.Available information in this form will be required to activate his/her account on Digital Universal Portal