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ADMISSION FORM FORM NO : 69

APPLICATION FOR ADMISSION TO FIRST YEAR OF FOUR YEAR FULL-TIME

DEGREE COURSE IN ENGINEERING FOR THE ACADEMIC YEAR 2011-12

FOR MINORITY QUOTA

Name of the Candidate : DCUNHA ILWIN IVAN JOLLY

PERSONAL DETAILS

Gender : Male

Date of Birth : 1991-01-24

E-mail : [email protected]

Telephone no : 28801420

Mobile no : 2147483647

Catholic : Yes

PASTE PHOTO

HERE

Address for Correspondence:

Address : 207 C-WING ADARSH AP ADAARSH ROAD MALAD(W

City / State : MUMBAI / Maharashtra

Country / Pin : India / 400064

Permanent Address:




Parents / Guardians Details:

Name : RITA DCUNHA

Phone : 28089691

Mobile / E-mail : 2147483647 / [email protected]

Qualification: : B.COM

Occupation: : BUSINESS

Company Name : 207 C-WING ADARSH APARTMENT ADARSH ROAD

Designation / Income : - / 3,50,0000




ACADEMIC DETAILS

MHT-CET Seat Number MHT-CET Merit No AIEEE Rank AIEEE Marks

MM311 40678 - 0

Physics Chemistry Maths Total

CET 14 29 42 85

Physics Chemistry Maths Aggregate Out of Marks HSC Percentage

HSC STD 12th. 70 71 67 403 600 67.17

Science Maths Aggregate Out of Marks SSC Percentage

SSC 86 42 493 650 75.85

LAST COLLEGE ATTENDED : ST. ANNES JR COLLEGE

STD 10TH BOARD : SSC

STD 12TH BOARD : HSC

DECLARATION : The information given by me in my application is true to the best of my knowledge and belief.I understand that if any of the statements madeby me in the application form or any information supplied by me in connection with my admission is, at any time found to be false or incorrect, my admission will be ,cancelled admission will be cancelled, fees forfeited and I may be expelled from the college by the Principal

Date :

Place : Signature of Candidate Signature of Parent


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UNDERTAKINGS

Declaration to be signed by the candidate:

The information given by me in my application is true to the best of my knowledge and belief.I understand thatif any of the statements made by me in the application form or any information supplied by me in connection withmy admission is late on at any time , found to be false or incorrect, my admission will be cancelled,fees forfeitedand i may be expelled from the college by the Principal.I have not been debarred anytime from appearing at anyexamination held by the Government constituted or statutory examination authority in India. I shall abide by therules imposed by the university from time to time such as imposing limit in the number of attempts permisssibleto pass any examination.

I hereby agree to conform to any rules, acts and laws enforced by government and I hereby undertake that,I willdo nothing either inside or outside the college which may result in disciplinary action against me under these rules,acts and laws referred to. I fully understand that the Principal of the college has a right to expel me from thecollege for any infrigement of the rules of conduct and discipline prescribed by the college or University orGovernment and the undertaking given above.

Condition of minimum attendance: I am fully aware that, I will not be allowed to appear for the examination ifI do not attend the minimum of 75 percent classes of theory, practical drawings etc. I am also aware that I will,

not be allowed to appear for the examination , if I fail to submit satisfactorily all the assignments,jobs, journals,drawings, and reports as specified by the University within stipulated time limit.

Place:

Date: Signature of the Candidate

Declaration to be signed by the Parent / Guardian

I,Mr. /Ms. ______________________________________________________________________________________

father / mother / guardian of Mr. / Ms. _______________________________________________________________declare that the particulars furnished to by my son / duaghter / ward such fees , charges etc. which

the Government of Maharashtra/ University of Mumbai may levy from time to time by due dateI also undertake and to pay any differences in the fees which may occur due to revision in fee structureany time during the academic year 2010-11 and in the event of failure on my part and / or on thepart of my son/ daughter/ ward to do so, suitable action as the college may deem fit be takenagainst him / her.

Place:

Date: Signature of the Parent/Guardian


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ATTACHMENTS

List of copies of Certificates to be attached with the application form: For office useAll copies must be attested S-SUBMITTED

X-NOT SUBMITTED

1. Proof of Roman Catholic Minority Status.

a) Baptism Certificate

b) Letter from Bishop

c) Affidavit from the ourt on Rs. 100 Stamp paper

2. Marksheet of qualifying examination(std. XII).

3. Marksheet of Std.10th examination.

4. MHT-CET-2011/AIEE 2011 Score Card

5. College Leaving certificate from the institution from which candidate passedqualifying exam or from the institute last attended

6. Physical Fitness Certificate from the institution from a Medical Practioner(specific mention of ability to handle manual work)

7. Certificate of Indian Nationality & Domicile

8. Eligibility certificate from Universityi(In case of candidate who passed qualifying.examination from outside Maharashtra,CBSE or ICSE).

9. Migration Certificate and Passing Certificate(In case of candidate.who passed qualifying examination from outside Maharashtra,CBSE or ICSE).

Total number of attested Certificate copies submitted:

Please do not attach certificates,which are not asked for.

Incomplete forms will not be accepted.

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