7/13/22, 2:28 PM

STUDENT COPY

SMT. P.D.HINDUJA TRUST`S, INSTITUTE OF MANAGEMENT STUDIES (31236)

315, NEW CHARNI ROAD,

Mumbai

Yashwantrao Chavan Maharashtra Open University

Application No :

Dnyangangotri Near Gangapur Dam, Nashik, Pin Code-422222, Maharashtra(India)

30695

Academic Year: 2022-2023

Distance Education
YCMOU Study Center Submission Slip
ADMISSION FORM
Instruction:
Please submit copy of this submission slip with following list of document to Study Center for Recommendation of Program for Admission
and/or Recommendation of Scholarship.

Please note that application shall be considered for admission only after recommendation by study center

If recommendation by study center not completed before last date of admission your application will be automatically cancelled. Please note that
university will not refund the fees in case of rejection by study center for want of Eligibility.

Course Applied for : P131 - B.C.A.(with Credits) - Distance Education - 2016 CGPA - F.Y.B.C.A Semester I 
(P131) PRN:
Application Date : 13/07/2022 Payment Category :
Exam Center Name [Code] : - [-]
1.Personal Information
Candidate's Name(Regional) : इन्शा
Candidate's Name as printed on School SIDDIQUI INSHA ABDUL SALAM

leaving/Passing Certificate : [*This name will appear on all University records/documents]

Father's/Husband's Name : ABDUL SALAM Mother's Name : TAUKEER BEGUM

Marital Status : UnMarried Mother Tongue : Hindi
Place Of Birth : Mumbai Gender : Female Date of Birth (DD/MM/YYYY) : 21/02/2005
Blood Group : BPositive Religion : Muslim Country of Citizenship : India
Height : Not Available Weight : Not Available Hemoglobin : Not Available
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
Location Area :
State : Maharashtra District : Mumbai Suburban Tehsil : Andheri City/Town/Village : Mumbai
Metropolitan
Address (House
D-3 Flat No 1 Sweekar Chs Ltd Khira Nagar Sv Road Santacruz West Pin Code : 400054
no,street/area/suburb etc.) :
Permanent Address :
Location Area :
State : Maharashtra District : Mumbai Suburban Tehsil : Andheri City/Town/Village : Mumbai
Metropolitan
Address : D-3 Flat No 1 Sweekar Chs Ltd Khira Nagar Sv Road Santacruz West Pin Code : 400054
Contact details
Mobile Number 9987739189 Primary Email ID: inshsiddiqui21@gmail.com
2.Legal Reservation Information
Category Type : Open Category : GEN
Is Guardian from EBC (Economic Backward
Is Specially Abled? No
Class)?  No
3.Social Information(Additional Inforamtion)
Not Applicable
Paper Selected for:
Semester I
AEC001 - English Communication CMP501 - Mathematics
CMP502 - Problem Solving Using Computers CMP503 - Programming Using C++
CMP701 - Lab: Mathematics CMP702 - Lab: Problem Solving Using Computers
CMP703 - Lab: Programming Using C++
Semester II

CMP504 - Statistics CMP505 - Data Structure Using C++

CMP506 - Computer Networks CMP704 - Lab: Statistics
CMP705 - Lab: Data Structure Using C++ CMP706 - Lab: Computer Networks
1/4
7/13/22, 2:28 PM
ENV121 - Environmental Studies

Medium of Instruction : English

Admission Fee Payment Details Fee Category : Regular Fees Over All Payment Status: : Paid
Adm Exam Fee - 1050 Alumni Membership Fee - 2
Tution Fee - 1000 Registration Fee - 200
Development Fund Fee - 4750 Other Fee - 200
Total : 7202
Payment
Installment Amount Transaction Date Transaction Number Transaction Type
Status
1 7202 Paid 13/07/2022 02:14:58 83401657721698920 Online Payment
4.Guardian Information
Occupation of Guardian : Service Annual Income of Guardian : 0
5.Educational Details
Month
Name of Name of Board/University and State of Name of Exam Certificate Mark Out
and Year CGPA %
Examination University School/College Seat No. No. Obtained Of
of Passing
MAHARASHTRA STATE BOARD OF MALTI JAYANT
Std 10th SECONDARY AND HIGHER DALAL HIGH June 2020 A278662 275936 421.00 500.00 --
-
-- 84.20
SECONDARY EDUCATION,Maharashtra SCHOOL
MAHARASHTRA STATE BOARD OF
RD NATIONAL
Std 12th Arts SECONDARY AND HIGHER June 2022 M137623 223953 515.00 600.00 --
-
-- 85.83
COLLEGE
SECONDARY EDUCATION,Maharashtra
Your Last Qualifying Exam: HSC [Arts]
7.Other Information
Would you like to apply for Hostel accommodation required NA
Required Documents and Certificates Section:
Statement of Marks of Qualifying Exam (पात्रता परीक्षेची गुण पत्रिका)

Passing Certificate of Std 10th.

Leaving Certificate.

Statement of Marks of Std 10th

Ration card Original or Readable attested copy in case income certificate is in the name of other parent

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 :30695 (SIDDIQUI INSHA ABDUL SALAM)
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

2/4
7/13/22, 2:28 PM
[STUDY CENTER COPY]

SMT. P.D.HINDUJA TRUST`S, INSTITUTE OF MANAGEMENT STUDIES (31236)

315, NEW CHARNI ROAD,

Mumbai

Yashwantrao Chavan Maharashtra Open University

Application No :

Dnyangangotri Near Gangapur Dam, Nashik, Pin Code-422222, Maharashtra(India)

30695

Academic Year: 2022-2023

Distance Education
YCMOU Study Center Submission Slip
ADMISSION FORM
Instruction:
Please submit copy of this submission slip with following list of document to Study Center for Recommendation of Program for Admission
and/or Recommendation of Scholarship.

Please note that application shall be considered for admission only after recommendation by study center

If recommendation by study center not completed before last date of admission your application will be automatically cancelled. Please note that
university will not refund the fees in case of rejection by study center for want of Eligibility.

Course Applied for : P131 - B.C.A.(with Credits) - Distance Education - 2016 CGPA - F.Y.B.C.A Semester I 
(P131) PRN:
Application Date : 13/07/2022 Payment Category :
Exam Center Name [Code] : - [-]
1.Personal Information
Candidate's Name(Regional) : इन्शा
Candidate's Name as printed on School SIDDIQUI INSHA ABDUL SALAM

leaving/Passing Certificate : [*This name will appear on all University records/documents]

Father's/Husband's Name : ABDUL SALAM Mother's Name : TAUKEER BEGUM

Marital Status : UnMarried Mother Tongue : Hindi
Place Of Birth : Mumbai Gender : Female Date of Birth (DD/MM/YYYY) : 21/02/2005
Blood Group : BPositive Religion : Muslim Country of Citizenship : India
Height : Not Available Weight : Not Available Hemoglobin : Not Available
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
Location Area :
State : Maharashtra District : Mumbai Suburban Tehsil : Andheri City/Town/Village : Mumbai
Metropolitan
Address (House
D-3 Flat No 1 Sweekar Chs Ltd Khira Nagar Sv Road Santacruz West Pin Code : 400054
no,street/area/suburb etc.) :
Permanent Address :
Location Area :
State : Maharashtra District : Mumbai Suburban Tehsil : Andheri City/Town/Village : Mumbai
Metropolitan
Address : D-3 Flat No 1 Sweekar Chs Ltd Khira Nagar Sv Road Santacruz West Pin Code : 400054
Contact details
Mobile Number 9987739189 Primary Email ID: inshsiddiqui21@gmail.com
2.Legal Reservation Information
Category Type : Open Category : GEN
Is Guardian from EBC (Economic Backward
Is Specially Abled? No
Class)?  No
3.Social Information(Additional Inforamtion)
Not Applicable
Paper Selected for:
Semester I
AEC001 - English Communication CMP501 - Mathematics
CMP502 - Problem Solving Using Computers CMP503 - Programming Using C++
CMP701 - Lab: Mathematics CMP702 - Lab: Problem Solving Using Computers
CMP703 - Lab: Programming Using C++
Semester II

CMP504 - Statistics CMP505 - Data Structure Using C++

CMP506 - Computer Networks CMP704 - Lab: Statistics
CMP705 - Lab: Data Structure Using C++ CMP706 - Lab: Computer Networks

3/4
7/13/22, 2:28 PM
ENV121 - Environmental Studies

Medium of Instruction : English

Admission Fee Payment Details Fee Category : Regular Fees Over All Payment Status: : Paid
Adm Exam Fee - 1050 Alumni Membership Fee - 2
Tution Fee - 1000 Registration Fee - 200
Development Fund Fee - 4750 Other Fee - 200
Total : 7202
Payment
Installment Amount Transaction Date Transaction Number Transaction Type
Status
1 7202 Paid 13/07/2022 02:14:58 83401657721698920 Online Payment
4.Guardian Information
Occupation of Guardian : Service Annual Income of Guardian : 0
5.Educational Details
Month
Name of Name of Board/University and State of Name of Exam Certificate Mark Out
and Year CGPA %
Examination University School/College Seat No. No. Obtained Of
of Passing
MAHARASHTRA STATE BOARD OF MALTI JAYANT
Std 10th SECONDARY AND HIGHER DALAL HIGH June 2020 A278662 275936 421.00 500.00 --
-
-- 84.20
SECONDARY EDUCATION,Maharashtra SCHOOL
MAHARASHTRA STATE BOARD OF
RD NATIONAL
Std 12th Arts SECONDARY AND HIGHER June 2022 M137623 223953 515.00 600.00 --
-
-- 85.83
COLLEGE
SECONDARY EDUCATION,Maharashtra
Your Last Qualifying Exam: HSC [Arts]
7.Other Information
Would you like to apply for Hostel accommodation required NA
Required Documents and Certificates Section:
Statement of Marks of Qualifying Exam (पात्रता परीक्षेची गुण पत्रिका)

Passing Certificate of Std 10th.

Leaving Certificate.

Statement of Marks of Std 10th

Ration card Original or Readable attested copy in case income certificate is in the name of other parent

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 :30695 (SIDDIQUI INSHA ABDUL SALAM)
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 Wed Jul 13 2022 14:26:20 GMT+0530 (India Standard Time)

4/4