College Code : 3201 Form No.

: T180194

RIZVI EDUCATION SOCIETY's

Rizvi College of Engineering

Rizvi Educational Complex, Off Carter Road, Bandra(W), Mumbai - 400050. Tel.: 022 26052072 / 26043866
Academic Year 2018-2019
APPLICATION FOR ADMISSION TO THIRD YEAR

BRANCH : Computer Engineering

UIN : 161P006 Affix a

Passport Size
Photograph
Adm. Year : 2018
Adm. Class : COMP (2018-2019) - TE
Adm. Type : Regular

Student Details :-
1) Full Name of the Candidate :
SURNAME : ASHFAQUE
FIRST NAME : ANSARI Please Sign Inside this box
MIDDLE NAME : SOFIYA NUSARAT with Black Ink Only

2) Sex : Female 5) Religion : Muslim

6) Caste : ISLAM
3) Date of Birth : 7) Subcaste :
In Words : 1997-03-18 8) Category : Open (--)
In Figures : EIGHTEEN MARCH NINETEEN NINETY
SEVEN 9) Place of Birth : BIHAR
4) Blood Group : O+ 10) Nationality : Indian

11) Local Address : 12) Permanent Address :

305/B WING,3RD FLR,LOKSEVA BUILDING,90 305/B WING,3RD FLR,LOKSEVA BUILDING,90
FEET ROAD,DHARAVI,MUMBAI, Pincode: FEET ROAD,DHARAVI,MUMBAI, Pincode:
400017 400017

13) Mobile No. 1 : 9320143609 16) Email ID : ansarisufiya103@gmail.com

14) Mobile No. 2 : 9320143609 17) Alt. Email ID : ansarisufiya103@gmail.com
15) Landline No. : 9769932271 / 9769932271

Parents Detail :-

18) Father's Full Name : 26) Mother's Full Name :

SURNAME : SURNAME :
FIRST NAME : MOHOMMAD FIRST NAME : ANSARI
MIDDLE NAME : ASHFAQUE ALAM MIDDLE NAME : ZAHADIA

19) Occupation : Business 27) Occupation : Housewife

20) Designation : GARMENTS 28) Designation : NO
21) Yearly Income : 465240 29) Yearly Income : 0
22) Office Address : 30) Office Address :
GNM-85/218,NAVRANG COMPOUND,NEAR NO, Pincode:
MAHIM FATAK,DHARAVI,MUMBAI, Pincode:
400017

23) Mobile No. : 31) Mobile No. : 9322404933

24) Landline No. (Res.) : 32) Landline No. (Res.) :
Landline No. (Off.) : 9320143609 Landline No. (Off.) :

25) Is your father a domicile of Maharashtra State ? NO

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 College Code : 3201 Form No. : T180194

Examination Detail :-
33) For Degree Students : ( S.E. / T.E. / B.E. )

A)
YEAR SEMESTER MONTH & YEAR OF PASSING No. of ATKT's REMARKS

I Dec - 2016 0
First Year

II May - 2017 0

III Dec - 2017 0

Second Year

IV May - 2018 0

V - 0
Third Year

VI - 0

(for office
34) Documents To Be Submitted: use only)

i. Xerox copy of all previous marksheets

ii. Xerox copy of all previous Fee-Receipts

iii. Progress Report Card of the Previous Year

Fees Details :-
35) Payment Mode : Demand Draft
36) Total Fees Amount (Rs.) : 66600
37) Name of Bank : State Bank of India,
38) DD No. / Cheque No. : 684227

Verified By
Admin. Staff / Examination Cell / Professor In-Charge

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College Code : 3201 Form No. : T180194

UNDERTAKING
1) I have read all rules of Admission and after understanding these rules thoroughly, I have filled in the application form for the current Year.
2) The information given by me in my application is true to the best of my knowledge and belief.
3) I have not been debarred from appearing at any examination held by any government constituted or statutory examination authority in India.
4) I fully understand that the offer of the course to me will be depending on my intense merit and availability of seat at the time of scrutiny of my application, when
I will actually report to the admission authority to the schedule of admission.
5) I understand that no document after the last date of submission will be entertained for the purpose of claims or concessions etc., in connection with admission,
unless otherwise mentioned in the rules.
6) I am fully aware that the competent authority or its representative will not make any correspondence with me regarding admission. I am aware that it is entirely
my responsibility to see the notice on the notice boards of concerned admission centre.
7) I am aware that any rule imposed by the University, such as imposing limits on the number of attempts permissible to pass any examination shall be binding on
me.
8) I hereby agree to confirm to any Rules, Acts and laws enforced by Government or management and I hereby undertake that, I will do nothing, either inside or
outside the college which may result in disciplinary action against me under these rules, acts and laws referred.
9) I fully understand that the principal of the college where I would be admitted has the right to expel me from the college, for any infringement of the rules of
conduct and discipline prescribed by the college or university or Governments and my undertaking given above.
10) Condition of Minimum Attendance : I am fully aware that, I will not be allowed to appear for the examination if I do not attend minimum 75 percent classes of
theory, practicals, drawing, etc. I am also aware that I will not be allowed to appear for the examination if failed to submit satisfactorily all the assignments,
jobs, journals, drawing, report as specified by the University with in the stipulated limit and I will not copy / write my assignment from any students in or
outside the college.
11) I am fulfy aware that mere is likely to be change in fee structure and i undertake to pay the fee whatsoever approved by the Competent Authority from time to
time.
12) I am fully aware that Ragging is an offence under MAHARASHTRA PROHIBITION OF RAGGING ACT, 1999. Ragging in all its forms is totally banned in
this institution including in its departments, constituent units, all its premises (academic, residential, sports, cafeteria, etc.) whether located within the campus or
outside and in all means of transportation of students whether public or private. The institution shall take strict action including but not limited to criminal
proceeding and/or cancellation of admission against those found guilty of ragging and/or of abetting ragging and the burden of proof shall hereby lie on the
perpetrator of alleged ragging and not on the victim. An offence of Ragging may be charged either on a written complaint by the affected or on independent
finding of the Anti Ragging Squad.

Date:

Name of the Candidate Signature of the Candidate

Name of the Parent / Guardian Signature of the Parent / Guardian

Student DP Student ADP

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