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For Office Use

Batch: Scrutiny Payment: Online/DD PI

Only Serial:

B.R. Harne College of Engineering and Technology, Karav (948)

At-Karav Post- Vangani Ambarnath Application No :
University of Mumbai 2810322
M.G.Road, Fort, Mumbai-400032, Maharashtra(India)
Academic Year: 2022-2023 Regular
APPLICATION FORM

Course Applied for : B.E.(with Credits) - Regular - CBCS - Computer Engineering - S.E. C-Scheme Sem III PRN:
(BECBCS1001)

Application Date : 27/11/2022 Payment Category :

1.Personal Information

Candidate's Name(Regional) : साळवी कौशल दिलीप

Candidate's Name as printed on Mark SALVI KAUSHAL DILIP
sheet : [*This name will appear on all University records/documents]
Father's/Husband's Name : DILIP SALVI Mother's Name : DARSHANA
Marital Status : UnMarried Mother Tongue : Marathi
Place Of Birth : Ratnagiri Gender : Male Date of Birth (DD/MM/YYYY) : 15/05/2003
Blood Group : OPositive Religion : Hindu Country of Citizenship : India
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
City/Town/Village :
State : Maharashtra District : Thane Tehsil : Kalyan Location Area : Urban
Dombivali
Address (House
Room No 8,Jay Maharashtra Niwas Chawl Retibunder Road Dombivali Pin Code : 421201
no,street/area/suburb etc.) :
Permanent Address :
Location Area : Not
State : Maharashtra District : Thane Tehsil : Kalyan City/Town/Village :
Available
Address : Room No 8,Jay Maharashtra Niwas Devichapada Dombivali Pin Code : 0
Contact details
Mobile Number 9082413166 Email ID: salvikaushal21@gmail.com
2.Legal Reservation Information
Category Type :
Category : OBC Sub Category : KUMBHAR
Reserved
Is Guardian from EBC (Economic Backward
Is Specially Abled? No
Class)? No
3.Social Information(Additional Inforamtion)
Not Applicable
Paper Selected for:
Sem III
CSC301 - Engineering Mathematics-III CSC302 - Discrete Structures and Graph Theory
CSC303 - Data Structure CSC304 - Digital Logic & Computer Architecture
CSC305 - Computer Graphics CSL301 - Data Structure Lab
CSL302 - Digital Logic & Computer Architecture Lab CSL303 - Computer Graphics Lab
CSL304 - Skill Base Lab Course: Object Oriented Programming With CSM301 - Mini Project – 1 A
Java
Sem IV

CSC401 - Engineering Mathematics-IV CSC402 - Analysis of Algorithm

CSC403 - Database Management System CSC404 - Operating System
CSC405 - Microprocessor CSL401 - Analysis of Algorithm Lab
CSL402 - Database Management System Lab CSL403 - Operating System Lab
CSL404 - Microprocessor Lab CSL405 - Skill Base Lab Courses: Python Programming
CSM401 - Mini Project 1-B

Medium of Instruction : English

4.Guardian Information
Occupation of Guardian : Service Annual Income of Guardian : 150000

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5.Educational Details
Month
Name of Name of Board/University and State of Name of Exam Certificate Mark
and Year Out of CGPA %
Examination University School/College Seat No. No. Obtained
of Passing
MAHARASHTRA STATE BOARD OF
SECONDARY AND HIGHER DON BOSCO
Std 10th June 2019 AO50507 082594 408.00 500.00 -- - -- 81.60
SECONDARY HIGH SCHOOL
EDUCATION,Maharashtra
Diploma : S. H. JONHALE
Maharashtra State Board of Technical
Computer POLYTECHNIC July 2022 107408 -- 1339.00 1750.00 -- - -- 76.51
Education,Maharashtra
Engineering DOMBIVALI
Your Last Qualifying Exam: Computer Engineering
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.

Certificate of Caste with Category.

Leaving Certificate.

Non Creamy Layer Certificate.

Domicile Certificate.

Certificate of Caste with Category.

Domicile Certificate.

Father’s Income certificate from Tahsildar.

School/College Leaving Certificate.

Statement of Marks of Std. 10th.

Mark/Grade Statement of Semester-I

Mark/Grade Statement of Semester-II

Mark/Grade Statement of Semester-III

Mark/Grade Statement of Semester-IV

Mark/Grade Statement of Semester-V

Mark/Grade Statement of Semester-VI

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 :2810322 (SALVI KAUSHAL DILIP) 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 Nov 27 2022 13:15:07 GMT+0530 (India Standard Time)

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