COEPTECHNOLOGICAL UNIVERSITY

SHIVAJINAGAR, PUNE - 411 005

(A Unitary Public University Government of Maharashtra)
Tel. No.020-25507660 E-mail: hostel@coeptech.ac.in Fax No.020-25507299
|Application for hostel admission 2023 - 2024]
11/22

Year of the study 2023-24 :- First Year B. Tech.

MH-CET Merit No. TLGM - MH-07
3 Name of the Branch PLANN NE
4 Category of the student :- OPEN SC/ ST/VJ /NTUNT2/NT3/ OBCISBC EWS /GOLLJKKI NRI/GULE/FN/PIO

Whether Physical with Disabilities? :-Xes /No

6 Whether SBC? :es / No
Institute Admission Category :- Through MH-CET / All India (JEE) (please tick as appropriate)
S. All India (Al) Merit Number
9. General Merit Number

1. A) Name of the student SH ARMA RIDDH) VIAYKU MAR

(In Block Letters)
B)Gender :-ate /Female
C) Blood Group
Address for Correspondence with contact No. i- 7Vshakha Appt, Behind LIC P Irdg
& E mail ID Enfont o IMA HALL CAMPROAD,
MALEGAON, NASIK,
3. Name & Address of Local Guardian

with contact No.

1. Name of the Father /Motirer /Guapdian i-SHARMA vIJAYkMAR RAMCHANDRA

5. Occupation and Annual income of Parent Teache, (Z60,ool
6. Details of AcademicRecord
a) Have you cleared all Courses? ;- Yes /No

b) Backlog* courses if any?

(" Backlog course means drop coursest unsuccessful (failed/ detained /withdrawn) courses.

Sr. No. Name of Exam Passed Year ofPassing Percentage

1. 10h Standard
12h Standard Feb-202\
Feb-2023
83·4o
18-83

Page l of2
 |VDERTAKING

of nny Looss
that all the statements made in th1s appication are true. complete and correct to the best
Ideciare
Hostel in torce during the course of ms
belief I have read rules and shall abde by the rules and regulations of the
and time upon viol.ation of
admission at an
reserves everv rnght to cancel mv hostel
stay, and Ienderstand that the authoritv
the ruies.
the nstitute norms
pav total bostel fees and depst ds per
At the tie of bostel ad missson. I wll ll lead to direct
ragging actiitV
aware that my nohcment tn an
I lnot indulz2 in 2t knd of razging Iam
the uajcrsit
FIR azainst me. and Iwill be expelled sm mediately from
be liable lor punvhuient, n
regulatho@s of the Hostcis, if admtled, and I wll
3 Ihereby agree to abide by the rules and
case Iam found disobey ing or guiity I
chargo Table harge of iC
and agrcs to pa thc nesrun nc
4 Iagree to be a member of bostel mos
preailmg horm
furthcr, shall abde bs thc reles ant rulev av per
mandatory in all the cases dur1ng hostei stay and
ckan andI shall orscrc the discpl1ne.
Ishall sec fhat m room & the premncs arc kgpt
rcquirsd mantcaance chargev of hostet.
Iflopt for summer term scommodatio, Ishall pav the
Iam aware that. bostel authoritic do Dot s (ord pcrmAon fot non23demie pic DICS Ciurvoi
Corpration tPOand Pmprr Chunchwad Munpal
The students staying in the arca of Pure MNpal
Corporation (PCMO ar not clgbie for Hosicl 4dmusot
orginal documents supporting thr apphcation
9 At the time of room allotat at te HostciIl prodecs all reics ant
form

"lace fune Reddhy

Date s/8 lao23 afure nf the Stusle nts

Permancat Address

7, Vishakha Appt, Behind LZc fs Khushiishama2626 Qqmail om

Con'act hone Vo tlacase of cncrgenc)7588S3SS)
Gamp Road, Malegaon g423697111,42149171D
Dist.Nasit.

Parcnts Tclephone Mobile o with STD code 23697111,

zEatsre fthe larents

CVijpyaumay amcandn2lavn)
Enct 1 lnstitute Ad mssor ( onfrn atson Letier Ihocp.
2 Instituic admissson Fee pavment feccipt ph Ao cof