Goa University

Taleigao Plateau, Sub Post Goa University, Goa 403206

India.
STUDENT REGISTRATION DETAILS FOR ACADEMIC YEAR 2021-2022
Enrolment No. Allotted 201909027 Eligiblity Case Number :
(if any) : (Wherever Applicable)

Student Registration Type : Goa University With P.R. Previous P.R. Number : 201909027
Number
Salutation : Miss Application Number : 109
1.Name(As per HSSC/Graduation MarkSheet in Block Letters:Leave one blank b/w words.(Enclose Copy of Mark Sheet))
SURVE SHRAVANI SUDHIR
2. Break up of name (Block Letters) :
Student First Name : SHRAVANI
Student Middle Name : SUDHIR
Surname/Last Name : SURVE
3. Father's Name (Block Letters) : SUDHIR RAJARAM SURVE
4. Mother's Name (Block Letters) : MRUNAL SUDHIR SURVE
5. Address : 3A, G8, Kurtarkar Nagari, Near Forest Office, Ponda, Pin Code : 403401
Goa.
6. Mobile Number : 7522948962 7. E-mail ID: SHRAVANISURVE09@GMAIL.COM
8. Gender Female 9. Marital Status Unmarried
(Male/Female) : (Single / Married /
Widow /Divorce) :
10. Admission 2021-2022 11. Date of Birth :
Session: (DD/MM/YYYY)
12. Religion Hinduism 13.Category UR
(Hindu/Christian/M (General/SC/ST/OB
uslim etc) : C) :
14. Nationality : Indian 15.Degree/Diploma Bachelor of Laws
16.Subject/Branch
Name:
17. Other Details ( indicate "Y" wherever applicable) :
a) InService :No b) Entrance Cleared (if any) : c) EBC* :No d) Domicile of Goa :Yes
e) NRI :No f) Physically Handicapped :No g)Registration/Enrolment Category:
18.Blood Group : B+ 19.Course Name :
20.Institution 21. Date of Joining
Name: Course:
22.Are you pass out from Goa State Board/University(indicate"Y"wherever applicable):Yes
23. Bank Name: 24. Branch Name:
25. Branch Code: 26.Bank Full
Address :
27. Bank Account 28. Account Type:
Number:
29. Bank Account 30. MICR Code:
Number In Words:
31. IFSC Code: 32. Pan Card Status:
33. Pan Number: 34. EPIC Card
Status:
35. EPIC Number: 36. Adhaar Card
Status:
37. Adhaar Card 38. Rural/Urban
No.: Category:
39. Country: India 40. State: Maharashtra
41. District: 42. Taluka:
43.Parent/Guardia 44. Parent/Guardian
n Email Id: Contact No.:
Qualifying Examination Passed :-
45. Name of Bachelor of Science 46. Subject: Botany (Honours)
Examination
Passed:
 Goa University
Taleigao Plateau, Sub Post Goa University, Goa 403206
India.
STUDENT REGISTRATION DETAILS FOR ACADEMIC YEAR 2021-2022
47. Mark 7.78 48. Roll Number: 3775
(%)/CGPA:
49. Year: 2021 50.Have Qualified for yes
Programme:
51.School/College P.E.S's Ravi Sitaram Naik College 52.Board University: Goa University
Address: of Arts and Science, Farmagudi,
Ponda, Goa.

List of Qualification(s):
S.No. Name of Exam Subject Year Roll No Address Marks%/ Board/University
Passed (CGPA)
1 Bachelor of Science Botany 2021 3775 P.E.S's Ravi 7.78 Goa University
(Honours) Sitaram Naik
College of Arts
and Science,
Farmagudi,
Ponda, Goa.

Fee Structure:
Sr. No Fee Head College Amount University Amount Total University Total
Fee Amount
1 Enrollment fee 25.00 575.00 600.00 600.00

Date : 18/01/2022 Signature of Student

Certified that information given above are verified and found correct and the admission of the student is confirmed / not
confirmed

Signature of the Principle / HOD

*EBC - Economically Backward Class.