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Chikitsak Samuhas S.S. And L.S.Patkar College of Arts And Science, V.P. Varde Application No
College of Commerce and Economics (156)
S. V. Road. Boriwali :
University of Mumbai
M.G.Road, Fort, Mumbai-400032, Maharashtra(India)
1225621
Academic Year: 2023-2024 Regular
APPLICATION FORM

Course Applied for : B.Sc. (Computer Science) (Autonomous)(with Credits) - PRN:

Regular - CBCS - F.Y.B.Sc. (Computer Science) (Autonomous) Sem I  (-)

Application Date : 11/06/2023 Payment Category :

1.Personal Information

Candidate's Name(Regional) : शेख उमरा इम्तियाज

Candidate's Name as printed on
Mark sheet :
Father's/Husband's Name :
Marital Status :
Place Of Birth : MUMBAI
Blood Group : OPositive
Is Student NRI/ Foreign National : No
Address For Correspondence :
State : Maharashtra
Address (House
90 Feet Road ,Opp Bhandari Compound Ganesh Nagar, Janta Seva Society Kandivali West Pin Code : 400067
no,street/area/suburb etc.) :
Permanent Address :
State : Maharashtra
Address :
Contact details
Mobile Number 8652564414
2.Legal Reservation Information
Category Type : Open
Is Specially Abled? No
3.Social Information(Additional Inforamtion)
Not Applicable
Paper Selected for:
Sem I
BSC CS 1.1 - Paper 1
BSC CS 1.3 - Paper 3
Sem II
SHAIKH UMRA IMTAYAZ
[*This name will appear on all University records/documents]
IMTAYAZ Mother's Name : KULSUM
UnMarried Mother Tongue : Hindi
Gender : Female Date of Birth (DD/MM/YYYY) : 08/12/2003
Religion : Muslim Country of Citizenship : India
Domicile State: Maharashtra
City/Town/Village :
District : Mumbai Suburban Tehsil : Boriwali Location Area : Urban
Mumbai
City/Town/Village :
District : Mumbai Suburban Tehsil : Boriwali Location Area : Urban
Mumbai
90 Feet Road, Near Bhandari Compound Ganesh Nagar, Janta Seva Society, Kandivali West Pin Code : 400067
Email ID: umraimtayaz@gmail.com
Category : GEN
Is Guardian from EBC (Economic Backward
Class)?  No
BSC CS 1.2 - Paper 2
BSC CS 1.4 - Paper 4

BSC CS 2.1 - Paper 5 BSC CS 2.2 - Paper 6

BSC CS 2.3 - Paper 7 BSC CS 2.4 - Paper 8

Medium of Instruction : English

4.Guardian Information
Occupation of Guardian : Service Annual Income of Guardian : 100000

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5.Educational Details
Month
Name of Name of Board/University and State Name of Exam Certificate Mark
and Year Out of CGPA %
Examination of University School/College Seat No. No. Obtained
of Passing
MAHARASHTRA STATE BOARD
NALANDA
OF SECONDARY AND HIGHER March
Std 10th ACADEMY SHAHU A331010 -- 295.00 500.00 -- - -- 59.00
SECONDARY 2020
SHI
EDUCATION,Maharashtra
MAHARASHTRA STATE BOARD NIRMAL JUNIOR
Std 12th OF SECONDARY AND HIGHER COLLEGE OF
May 2023 M089949 -- 317.00 600.00 -- - -- 52.83
Science SECONDARY COMMERCE AND
EDUCATION,Maharashtra SCIENCE
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.

Passing Certificate of Std 10th.

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 :1225621 (SHAIKH UMRA IMTAYAZ) 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 Sun Jun 11 2023 19:49:46 GMT+0530 (India Standard Time)

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