Elphinstone College

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APPLICATION FOR ADMISSION TO FIRST YEAR B.A. | APPLICATION NO.: FYBA_122 | OUTSIDER
PERSONAL INFORMATION 1. Name (as mentioned in SSC mark sheet) Surname First Name Father's Name Mother's Name TAMBE MR. SANDESH SIDDHARTH SUPRIYA Please paste here a RECENT photograph

2. Date of Birth (as mentioned in School Leaving Certificate) In Figures In Words 1994-04-26 TWENTY SIXTH APRIL NINETEEN NINETY FOUR

3. Contact Details (Please do not repeat name) Local Address 27/68, B. D. D. CHAWL, N. M. JOSHI MARG, LOWER PAREL

PIN Code 400013

Landline

Mobile 9004364291

Native Place Address 27/68, B. D. D. CHAWL, N. M. JOSHI MARG, LOWER PAREL

PIN Code 400013 4. Additional Details Caste SC Marital Status Unmarried ACADEMIC INFORMATION Examination Passed S.S.C/ICSE/CBSE/NIOS

Landline

Mobile 9004364291

Physically Handicapped No Nationality INDIAN

Special Category N.A. Blood Group N. A.

School / College MAHARASHTRA HIGHSCHOOL NO. 2 DADAR MUMBAI 28 G. E. I'S NEW HIGH SCHOOL & JR. COLLEGE KALYAN (W) G. E. I'S NEW HIGH SCHOOL & JR. COLLEGE KALYAN (W)

Board / University MAHARASHTRA

Month & Year of Passing 2008-2009

Marks Obtained 283

Out of 650

Percentage 43.53

Class or Grade B

F.Y.J.C (XI) S.Y.J.C (XII) - Arts

MAHARASHTRA MAHARASHTRA

2009-2010 2010-2011

366 286

700 600

52.28 47.67

B B

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Elphinstone College

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EXTRA CURRICULAR ACTIVITIES Event Name 1 2 3 N.A. N.A. N.A. Year N.A. N.A. N.A. Level N.A. N.A. N.A. Organizers N.A. N.A. N.A. Place Obtained N.A. N.A. N.A.

DOCUMENT INFORMATION 1. Provisional / Final Eligibility Certificate from HSC Board is obtained and attached / not obtained. Certificate No. N.A. 2. Details of School / College Leaving / Transfer Certificate enclosed. Institution G. E. I'S NEW HIGH SCHOOL & JR. COLLEGE KALYAN (W) Registration No. 15414 PARENT / GUARDIAN INFORMATION Father / Guardian's Details Name SIDDHARTH DEVRAM TAMBE Occupation SERVICE Annual Income 140000 Office Address BMC, E WARD, BYCULLA , MUMBAI Dated 31-05-2011 Dated N.A.

PIN Code 400008 Mother's Details Name SUPRIYA S TAMBE

Landline N.A.

Mobile N.A.

Occupation N.A.

Annual Income N.A.

Office Address N.A.

PIN Code N.A. STATEMENT OF DECLARATIONS

Landline N.A.

Mobile N.A.

1. I/my ward certify that all the above details are true to the best of my knowledge and belief. If any statement is found to be incorrect, my/my ward's admission may be cancelled. 2. I/my ward agree to conform to the Rules and Regulations at present in force as specified in the prospectus, and those which may be formulated from time to time. I/my ward further understand that a breach of this undertaking will result in disciplinary action, including dismissal, against me/my ward. 3. I/my ward agree, if admitted, to be regular in attendance in all lectures, tutorials, practicals, tests and examinations. In case I/my ward am/is found to have less than 75 percent attendance or if my/my ward's progress in the examinations is not satisfactory, I/my ward may not be allowed to appear for the final examination. 4. I/my ward agree/s that I/my ward may be considered liable to any disciplinary action such as punishment, fine, cancellation of performance at an examination, cancellation of admission, etc in case I/my ward indulge/s in any of the following: malpractices in an examination (copying, etc), not displaying the Identity Card on person in the College premises, misbehaviour with any staff member, damaging College property, not paying College fees, and fines within the stipulated time.

Date

Parent / Guardian's Signature

Student's Signature

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