10/26/21, 2:09 PM

For Office Use

Batch: Scrutiny Payment: Online/DD PI

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Birla College of Arts, Science and Commerce (23)

Birla College Road.

Kalyan
Application No :

University of Mumbai 2997167

M.G.Road, Fort, Mumbai-400032, Maharashtra(India)

Academic Year: 2021-2022

Regular
APPLICATION FORM

Course Applied for : B.Voc.(Autonomous)(with Credits) - Regular - CBCS - Cyber Security and Forensics - F.Y.B.Voc. PRN:
(Autonomous) Sem I 
(-)

Application Date : 26/10/2021 Payment Category :

1.Personal Information

Candidate's Name(Regional) : अन्सारी शाजान रिजवान

Candidate's Name as printed on Mark ANSARI SHAZAN RIZWAN

sheet : [*This name will appear on all University records/documents]

Father's/Husband's Name : RIZWAN ANSARI Mother's Name : TARANNUM

Marital Status : UnMarried Mother Tongue : Urdu
Place Of Birth : BHIWANDI Gender : Male Date of Birth (DD/MM/YYYY) : 03/10/2003
Blood Group : Religion : Muslim Country of Citizenship : India
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
City/Town/Village :
State : Maharashtra District : Thane Tehsil : Bhiwandi Location Area : Urban
BHIWANDI
Address (House
HOUSE NO 12/3, GROUND FLOOR, BUDDHA WADA, BHIWANDI Pin Code : 421302
no,street/area/suburb etc.) :
Permanent Address :
City/Town/Village :
State : Maharashtra District : Thane Tehsil : Bhiwandi Location Area : Urban
BHIWANDI
Address : HOUSE NO 12/3, GROUND FLOOR, BUDDHA WADA, BHIWANDI Pin Code : 421302
Contact details
Mobile Number 7498150444 Email ID: ansarishazan444@gmail.com
2.Legal Reservation Information
Category Type :
Category : OBC Sub Category : JULAHA
Reserved
Is Guardian from EBC (Economic Backward
Is Specially Abled? No
Class)?  No
3.Social Information(Additional Inforamtion)

Paper Selected for:

Sem I
BVOCACSF101 - Paper 1 BVOCACSF102 - Paper 2
BVOCACSF103 - Paper 3 BVOCACSF104 - Paper 4
Sem II

BVOCACSF201 - Paper 1 BVOCACSF202 - Paper 2

BVOCACSF203 - Paper 3 BVOCACSF204 - Paper 4

Medium of Instruction : English

4.Guardian Information
Occupation of Guardian : Laborer Annual Income of Guardian : 0
5.Educational Details
Month
Name of Name of Board/University and State Exam Certificate Mark
Name of School/College and Year Out of CGPA %
Examination of University Seat No. No. Obtained
of Passing
MAHARASHTRA STATE BOARD THE SCHOLARS
OF SECONDARY AND HIGHER ENGLISH MEDIUM March
Std 10th A095987 -- 301.00 500.00 --
-
-- 60.20
SECONDARY HIGH SCHOOL AND 2019
EDUCATION,Maharashtra JR COLLEGE
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Month
Name of Name of Board/University and State Exam Certificate Mark
Name of School/College and Year Out of CGPA %
Examination of University Seat No. No. Obtained
of Passing
MAHARASHTRA STATE BOARD THE SCHOLARS
Std 12th OF SECONDARY AND HIGHER ENGLISH MEDIUM February
M022459 -- 443.00 600.00 --
-
-- 73.83
Science SECONDARY HIGH SCHOOL AND 2021
EDUCATION,Maharashtra JR COLLEGE
Your Last Qualifying Exam: HSC/Std 12th [Science]
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.

Certificate of Caste with Category.

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 :2997167 (ANSARI SHAZAN RIZWAN)
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 Remarks / Particulars / Recommendations Signature and Date
Admission Clerk
Admission
Committee
Accountant/Cashier Cash Received: INR Receipt No.: Date:
Registrar/Office
Superintendent
Document printed on Tue Oct 26 2021 14:09:55 GMT+0530 (India Standard Time)

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