NORTH MAHARASHTRA UNIVERSITY, JALGAON Application for Degree Certificate

REGULAR DEGREE To, The Controller of Examinations, North Maharashtra University, Jalgaon - 425 001 Sir, I request to confer a degree of this University on me at the ensuring Convocation to be held in - 2014 Personal Details Applicant Name:- JADHAV NAMRATA SURESH Mothers Name:- JADHAV NIRMALA SURESH Date of Birth:- 10/06/1986 Gender:- FEMALE Category:- OBC

Application ID 731

Address:- C/O- MR. SURESH CHINDHU JADHAV, "CHINTAMANI" NEAR AMAR CINEMA, BEHIND SHIVAJI NATYAGRIHA, NANDURBAR, NANDURBAR, NANDURBAR, MAHARASHTRA, 425412 Email ID:- namrata.pw@gmail.com Contact Details:- 9421476465/02564-221566

Educational Details Faculty:- ENGINEERING & TECHNOLOGY Subject:- B.E. ELECTRONICS & TELECOMMUNICATION (6102) College Code:- 200004 PRN:- 42652404B Student Status:- CIS[Class Improvement Scheme] PhD/MPhil NOT APPLICABLE Notification No.:Fee Details Amount:- 350/Documents Attached: (Tick only those check boxes in front of the document names that you are submitting along with this Application Form.)
Receipt of Challan (Part C)

Month and Year of Examination:- May - 2010 Seat No:- 49630 Convocation Status:- IN ABSENTIA Ph.D./M.Phil Viva NOT APPLICABLE Date:-

[ ] First Year Marksheet [ ] Second Year Marksheet [ ]

Third Year Marksheet

[ ]

Fourth Year Marksheet

[ ]

Fifth Year Marksheet

[ ]

Sr No. 1. 2. 3. Place: Printed On: 01/09/2013

Declaration I declare that all statements in this application are true, complete and correct to the best of my knowledge and belief and in the event of any information being found false or incorrect or any ineligibility being detected my application form will be summarily rejected. I have enclosed the receipt/demand draft payable at Jalgaon of requisite amount and all attested photocopies of marksheet from first year up to final year I have noted that if my application is found incomplete, defective and received late due to any reason in the university office, the same is liable to be rejected summarily and no correspondence will be entertained in this regard.

Signature of Candidate

North Maharashtra University, Jalgaon

Part A
Challan for Degree Application Unique No. :731 For The Bank Challan Code 90403 IFSC Code-CBI No.: Central Bank Acc. No. : The Sum of Rs. 350/CBIN0284435 3266557536 Course: Convocation

North Maharashtra University, Jalgaon

Part B
Challan for Degree Application Unique No. :731 For The Finance Department Challan Code 90403 IFSC Code-CBI No.: Central Bank Acc. No. : The Sum of Rs. 350/CBIN0284435 3266557536 Course: Convocation

Inword Rs. : Three hundred and fifty only

Inword Rs. : Three hundred and fifty only

Name of Payee : JADHAV NAMRATA SURESH

Address : C/O- MR. SURESH CHINDHU JADHAV, "CHINTAMANI" NEAR AMAR CINEMA, BEHIND SHIVAJI NATYAGRIHA, NANDURBAR Sr. No. 1 2 3 4 Account Admission Fee Deposit Amount Other Fees (Convocation) Other Recoveries Total Rs. Date : / /201 Recieving Cashier 21001100 --350/Code ----350/Amount

Name of Payee : JADHAV NAMRATA SURESH

Address : C/O- MR. SURESH CHINDHU JADHAV, "CHINTAMANI" NEAR AMAR CINEMA, BEHIND SHIVAJI NATYAGRIHA, NANDURBAR Sr. No. 1 2 3 4 Account Admission Fee Deposit Amount Other Fees (Convocation) Other Recoveries Total Rs. Date : / /201 Recieving Cashier 21001100 --350/Code ----350/Amount

Payee's Signature

Seal of the Bank

Payee's Signature

Seal of the Bank

North Maharashtra University, Jalgaon

Part C
Challan for Degree Application Unique No. :731 For The Convocation Department (To be attached with the application form) Challan Code 90403 IFSC Code-CBI No.: Central Bank Acc. No. : The Sum of Rs. 350/CBIN0284435 3266557536 Course: Convocation

North Maharashtra University, Jalgaon

Part D
Challan for Degree Application Unique No. :731 For The Applicant (To be kept with Applicant) Challan Code 90403 IFSC Code-CBI No.: Central Bank Acc. No. : The Sum of Rs. 350/CBIN0284435 3266557536 Course: Convocation

Inword Rs. : Three hundred and fifty only

Inword Rs. : Three hundred and fifty only

Name of Payee : JADHAV NAMRATA SURESH

Address : C/O- MR. SURESH CHINDHU JADHAV, "CHINTAMANI" NEAR AMAR CINEMA, BEHIND SHIVAJI NATYAGRIHA, NANDURBAR Sr. No. 1 2 3 4 Account Admission Fee Deposit Amount Other Fees (Convocation) Other Recoveries Total Rs. Date : / /201 Recieving Cashier 21001100 --350/Code ----350/Amount

Name of Payee : JADHAV NAMRATA SURESH

Address : C/O- MR. SURESH CHINDHU JADHAV, "CHINTAMANI" NEAR AMAR CINEMA, BEHIND SHIVAJI NATYAGRIHA, NANDURBAR Sr. No. 1 2 3 4 Account Admission Fee Deposit Amount Other Fees (Convocation) Other Recoveries Total Rs. Date : / /201 Recieving Cashier 21001100 --350/Code ----350/Amount

Payee's Signature

Seal of the Bank

Payee's Signature

Seal of the Bank