SYMBIOSIS

Centre for Distance Learning (SCDL)

Symbiosis Bhavan, 1065 B, Gokhale Cross Road, Model Colony, Pune - 411016, Maharashtra, India.
Tel.: 020 66211000-20 | Fax: 020 66211040 / 41 | www.scdl.net

Please read the instructions on website before filling the Application Form

Application No. 95161 Paste one recent

front face passport size
To, colour photo & attach another
The Director, photo
at the top corner
I request for grant of admission to the below mentioned program being offered by your institute
for the current academic year under the student Category - General Note: Side face, School age
& Selfie photos not accepted
Are you alumni or existing student of SCDL? If yes write your registration no.

Program / Course: Post Graduate Diploma in Business Administration

A) Personal Details (Name of the applicant should be as per Bachelor Degree Certificate attached. In case of name change, attach
the required document.)

First Name: AMIT Middle Name: WAMAN Last Name: BANKAR

Gender: Male Marital Status: Married Date of Birth: 09 Feb 1975

Caste Category: Are you physically handicapped?: No

B) Postal Address Please use spaces and / or commas wherever applicable.

Communication Address: (Students should take utmost care in writing complete address so as to receive all communication, Study Kit, ID Card
etc. on this address without any delay.) Re-dispatch due to incorrect address will be charged to the student.)

Address: 755, New Subedar Layout P.O. Ayodhyanagar

Land Mark: Behind Gajanan Vidyalaya

City: Nagpur State: Maharashtra Country: India Pin Code: 440024

Mobile No. 7020736605 Alt Contact No. 8806630743 Email ID: [email protected]
CONTACT NO. & EMAIL ID IS COMPULSORY. Ensure your contact no. and email ID is correctly mentioned. SCDL sends many important
information from time to time. Any change in communication address/ contact no. / email ID must be immediately communicated to SCDL.

Permanent Address:
Address: 755, New Subedar Layout P.O. Ayodhyanagar
Behind Gajanan Vidyalaya

City: Nagpur State: Maharashtra Country: India Pin Code: 440024

C) Academic Details: It is mandatory to mention your academic details; without which your form will not be processed.
Examination School / College / Year of Year of % Mode of Medium of Instruction in
Stream
Degree University Admission Passing Marks Education School / College
Bachelor
Mangalore University BE 1993 1998 63.00 Regular English
Degree

Reason for admission being provisional / rejected

Doc. not attested by class 1 Gazette Officer HSC certificate attested copy reqd. Photo reqd.
FOR Bachelor deg. cert. attested copy reqd. Name change doc. reqd.
Govt. Photo Id proof reqd.
SCDL All/Final Yr. marksheet attested copy reqd. Internet marksheet not attested by resp. college principal NRI proof reqd.
USE Undertaking/ Form not signed Defence Proof Required
ONLY
Admission Status Form Status Admission Date Registration Number
Confirmed Provisional A H R DD MM YYYY

Application No. 95161 Generated On: 02 May 2020

D) Other Information:
I received information about SCDL programs from: Online advt By Profession I am : Working
E) Work Experience Details:
Name & Address of Organization:

Suryodaya College Of Engineering & Technology, Nagpur E-mail: [email protected]

Near Dighori Toll Naka Umrer Road Nagpur

Current Designation: Training & Placement Officer Contact Tel No.: 8888823166
F) Fee Payment:
Applicant is required to pay full course fee as prescribed in prospectus, immediately on grant of confirmed admission to the applied program.
Mode of Payment : Fees can be paid Online through payment gateway or via a Demand Draft (DD) drawn in the favour of ³The Director, SCDL
Pune´payable at Pune. SCDL will not be responsible for depositing of any DD which is not payable in Pune or cash sent by post/courier.

DD Details: No.: , Date: , Amt.: , Bank:

Any personal / banker¶s cheque / co-operative bank DD for any kind of fee payment is not accepted.

Payment Date Order ID Fee Description Fee Amount (Rs.) Total Paid Fee (Rs.)
20 Apr 2020 P200420201234402929U60026 Application Form Fee 1000 1000

Check list of documents to be enclosed by the applicant along with the duly filled and signed application form.
Two passport size colour photographs
Clear photocopy of any one photo identity (e.g.: Passport Copy, PAN/Aadhar/Election Card, Driving Licence).
Photocopy of XII std. Marksheet & Bachelor Degree Completion Certificate/Provisional or Passing Certificate, duly attested by a class 1 Gazette
Officer or Notarized by notary, as per the applicable eligibility for the applied program.
Defence / Police / Paramilitary category proof: service certificate / discharge book / dependent certificate (as applicable)
Name Change document (if applicable).
For International/SAARC category student, photocopy of passport page showing valid visa of foreign country.

Note: SCDL reserves the right to ask for additional documents if necessary, to verify academic qualification of student. Student is
liable to submit the required documents within the specified timeline prescribed by SCDL.

Certificate of Undertaking

I AMIT WAMAN BANKAR Accept that I have read all the instructions and that I give my consent to be bound by this Certificate of Undertaking. I am
signing this Application Form electronically. I am aware and agree that I have to manually sign the form before I dispatch it to SCDL & understand that:

‡ I am enrolling for session commencing from July-2020 and I have read in the prospectus the fee policies, eligibility criteria and all other
information carefully.
‡ I am aware that there is no caste based reservation or fee concession for seeking admission to programs offered by SCDL. The caste details
are captured only for Statistical Analysis.
‡ Program validity of my enrolled program & registration validity will remain the same as mentioned on the ID card & understand that the
information/policies & details given herein website, prospectus & any other communications of SCDL is subject to change from time to time.
‡ The information provided by me in this application form is true and correct to the best of my knowledge. And I am fully aware that in case any
information provided is found false or erroneous, it will result in cancellation of my registration / admission.
‡ I have read the prospectus carefully and have understood the rules specially:- (a) Provisional Admission (b) Payment of program fees, exam
fee and mode of payment (c) Cancellation of admission ( d) Rules for refund of program fee (e) Late fees (f) Rules related to forfeiture of
unidentified fees, excess fees and other unclaimed fees (g) Rules regarding evaluation, additional attempts (h) Award of Diploma and
registration validity (i) Jurisdiction.
‡ SCDL shall be conducting online classes & online faculty chat as per schedule decided by SCDL. I have also understood that the examination
system & assignments at SCDL are computer based & I have to appear for exams at nearest designated SCDL exam centre.
‡ SCDL has provided Student Grievance Redressal Forum, a body independent of SCDL headed by legal luminary to enable the students to get
their grievances, if any, redressed. I undertake that I will approach the said Student Grievance Redressal Forum to get my grievance, if any,
redressed before taking any legal recourse.
‡ The institute reserves the right to amend the rules and regulation, whenever and wherever considered necessary and appropriate related to
course content, passing requirements, eligibility criteria for examinations, fee structure, refund policy, admission cancellation policies and
rules, curriculum and course content, examination pattern, policies and timelines, certification and designation, assignment pattern,
examination and contact program centres and such other matters, as may be considered relevant.
‡ I have to immediately inform SCDL if there is any change in communication details.
‡ I absolve Symbiosis Centre for Distance Learning (SCDL) from any responsibility arising out of false information / errors / mistakes / delay in
adhering to prescribed time-lines on my part.
‡ I have read the refund policy of the institute, mentioned in the prospectus & I will not claim/apply for any refund of fees paid, for the enrolled
program at SCDL after 20th August 2020.
‡ I may be informed on my personal email id and or mobile no., (by email / sms / call) various updates and important information about activities
taking place at SCDL from time to time with respect to my admission.

Date: DD/MM/YYYY Place: AMIT WAMAN BANKAR

(Signature of Applicant)
(Note: Application form without signature & having any other deficiencies will not be processed & application fee will not be refunded.)
Center Name: 0

Application No. 95161 Generated On: 02 May 2020