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Keraleeya Samajam (REGD.) Dombivlis Model College (102)

Kanchangaon, Khambalpada, Near RBT School, Thakurli (E). Kalyan Application No :
University of Mumbai
M.G.Road, Fort, Mumbai-400032, Maharashtra(India)
1277837
Academic Year: 2023-2024 Regular
APPLICATION FORM

Course Applied for : B.M.S.(Autonomous)(with Credits) - Regular - ABC ID: 399-556-265-737 PRN:
CBCS - F.Y. B.M.S.(Autonomous) Sem I (-)

Application Date : 11/06/2023 Payment Category : Candidate

Photo
1.Personal Information
Candidate's Name(Regional) : विनायक विकास विश्वकर्मा
Candidate's Name as printed VINAYAK VIKAS VISHWAKARMA
on Mark sheet : [*This name will appear on all University records/documents]
Mother's
Father's/Husband's Name : VINAYAK PUSHPA
Name :
Mother
Marital Status : UnMarried Hindi
Tongue :
Place Of Birth : Parel Gender : Male Date of Birth (DD/MM/YYYY) : 10/03/2005
Blood Group : Religion : Hindu Country of Citizenship : India
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
City/Town/Village : Location Area :
State : Maharashtra District : Thane Tehsil : Kalyan
Dombivli Semiurban
Address (House
no,street/area/suburb B Type A Wing/Room No-106/Siddhi Complex Kopar Road Kopar Goan Pin Code : 421202
etc.) :
Permanent Address :
City/Town/Village : Location Area :
State : Maharashtra District : Thane Tehsil : Kalyan
Dombivli Semiurban
Address : B Type A Wing/Room No-106/Siddhi Complex Kopar Road Kopar Goan Pin Code : 421202
Contact details
Mobile
9321452759 Email ID: [email protected]
Number
2.Legal Reservation Information
Category Type :
Category : GEN
Open
Is Guardian from EBC (Economic
Is Specially Abled? No
Backward Class)? No
3.Social Information(Additional Inforamtion)
Not Applicable
Paper Selected for:
Sem I
BMS1001 - Paper 1 BMS1002 - Paper 2
BMS1003 - Paper 3 BMS1004 - Paper 4
Sem II

BMS2001 - Paper 1 BMS2002 - Paper 2

BMS2003 - Paper 3 BMS2004 - Paper 4
Medium of Instruction : English
4.Guardian Information
Occupation of Guardian : Laborer Annual Income of Guardian : 120000
5.Educational Details
Month
Name of Name of Board/University Name of and Exam Certificate Mark Out
CGPA %
Examination and State of University School/College Year of Seat No. No. Obtained of
Passing
MAHARASHTRA STATE
Std 12th BOARD OF SECONDARY AND MODEL June
M180153 -- 64.17 100.00 -- - -- 64.17
Commerce HIGHER SECONDARY COLLEGE 2023
EDUCATION,Maharashtra
Your Last Qualifying Exam: HSC/Std 12th [Commerce]
7.Other Information
Would you like to apply for Hostel accommodation required NA
Required Documents and Certificates Section:
Passing Certificate of Std 12th / Statement of Marks of Std 12th OR Original Passing Certificate /Statement of Marks of Last
Qualifying Exam like degree,diploma,etc.

Leaving Certificate.

DECLARATION
I hereby declare that all the information furnished by me in this application form is true, complete and correct to the best of my
knowledge and belief. I do understand that I need to obtain and produce all the required documents. I Application No :1277837
(VINAYAK VIKAS VISHWAKARMA) admit to having understood what constitutes ragging and sexual harassment. I have read the
guidelines related to the same. I hereby affirm that if found guilty of ragging or sexual harassment I am liable for punishment
according to the university regulations.

Place : Date :
( Signature of the Candidate )
For College/Institute/Study Center Use Only
Designation Signature and
Remarks / Particulars / Recommendations
Date
Admission Clerk
Admission
Committee
Accountant/Cashier Cash Received: INR Receipt No.: Date:
Registrar/Office
Superintendent
Document printed on Mon Jun 12 2023 10:19:18 GMT+0530 (India Standard Time)