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FORM OF APPLICATION FOR ADMISSION I. D. No.

Academic Year - 2021 - 22 College Code : 130021
R. S. S. P. Mandal Ltd. Chalisgaon Sanchalit
Form No.
Nanasaheb Yashavantrao Narayanrao Chavan
Arts, Science & Commerce College, Chalisgaon
NAAC Re-accredited (Third Cycle) ‘B++’ Grade
For Course Admitted to Division : ADDHAR CARD No.
College Please Paste a
use only Admission Date : Roll No. passport size
(35 mm X 45 mm)
Important Instructions to students :
Photograph here,
1. Use black ink to fill in the form and DO NOT overwrite. Do not staple.
2. Fill in all fields in CAPITAL letters only Photo should not
Student should sign strictly inside
exceed the borders.
3. Put ( ) whenever applicable. this box only with black ink.

Course Applied for e.g. B.A./B.Com./B.Sc./B.C.A./B.M.S.(B.B.M.)/M.Sc./M.M.S.(M.B.M.)

Course part or Semester applied for (e.g. FY / SY / TY / SEM - I / II / III / IV / V / VI)

Appling for concession EBC / SC / ST / NT / OBC / SBC /

PTC / STC / FREEDOM FIGHTER / Ex Service man /
1. Personal Information Section
Last Name (surname) First Name Middle
Name of the Student
(In case of changed name, write current name)
Name of the student : (In Devnagri script) ‘amR>r
Name of the Student as printed on Std. 10
Marksheet
(write the name as it should appear on the marksheet)
Fathe’s / Husband’s Name :
Mother’s Name :
Previous name of the Student :
(In case of changed name)

Reason for name change : Wilingly/ After Marriage Marital Status : Unmarried Married/ Divorced
Windowed/ Dieserted
(Check ( ) whichever is applicable) (Check ( ) whichever is applicable)
Date of Birth (DD/MM/YYYY) : / / : Gender Male Female

Place of Birth : Blood Group (With Rh) :

Religion : Citizen of (country name) :

Address for Correspondence

State : District Tehsil : City / Town / Village :
Address (House no, street/area/suburb etc.) :

PIN Code :
Parmanent Address (Write only if different from ‘Address for Correspondence’) :

State : District Tehsil : City / Town / Village :

Address (House no, street/area etc.) : PIN Code :

Phone # 1 : STD Code : Phone No.

Contact Details
Phone # 2 : STD Code : Phone No.
Mobile
No. Email ID :

(For ex. + 9 1 9 4 2 3 5 8 9 6 9 3)
 Form No.
2. Legal Reservation Information Selection
(Check ( ) Whichever is applicable)
Domicile of State : Maharashtra Category : Open Reserved If Reserved :
DT/(A) NT/(B) NT (C)
Other State Specify : NT/(D) OBC/ SBC

If Physically Challenged :

Visually Impaired/ Speech and or Hearing impaired/

Caste : Sub - Caste : Orthopedic Discoredr or Mentally Retarded

3. Social Reservation information Section

(Check ( ) whichever is applicable, write name of supporting document attached, in section 6.)
Ex-Seviceman / Ward of Ex-Serviceman Member of Project Affected Family
Active-Serviceman/Ward of Active-Serviceman Member of Earthquake Affected Family
Freedom Fighter / Ward of Freedom Fighter Member of Flood / Famine Affected Family
Ward of Primary Teacher Resident of Tribal Area
Ward of Secondary Teacher Kashmir Migrant
Deserted / Divorced / Windowed Woman

4. Selected. Opted Papers Section (write paper codes or paper Name only, in the boxes)
(Of attach list as per syllabus separated)

Year / Semester : I, III, V Year / Semester : II, IV, VI (If decided in first Semester only)

Code Paper Name Code Paper Name

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12
5. Educational Detail Section (Write ‘YES’ in last column, against the qualifying, examination, on the basis of which
you are seeking admission to the said Program / Course. Write ‘No’ in front of other examinations)

Last College Attended Year : Roll No./PRN :

Examinaion Marksheet Grand / Total Qualifying

Name of Name of Board/ Name of School/ Year &Month
Seat No. Satement Statement Out of Examination ?
Examination University College of Passing
(If Any) No. No. (Yes / No)

Std. 10th
(Details are
Mandatory)

Std. 12th

F.Y.

S.Y.

T.Y.

6. Guardian Information Section

Guardian’s Name :

Occupation of the Guardian : Annual Income of the Guardian (Rs.) :

Service / Business / Profession / (Last Financial Year)

Farmer / Laborer / Retired /

Relationship of Guardian with application : Phone No.

7. Attached Documents and Certificates Section :

Sr.No. Name of the Document / Certificate Original / Attested True Copy Attached (Yes / No)

1. Mark Sheet of Std. 10th Attested True Copy (Mandatory)

2. Mark Sheet of Std. 12th Original & Two Attested True Copies

3. Leaving Certificate Original & Two Attested True Copies

4. Cetificate of caste with category Attested True Copy

5. Non Creamy Layer Certificate Attested True Copy

Affidavit for changed name/

6. Attested True Copy
Marriage Certificate/Gov. Gazette

7. Domicile Certificate Attested True Copy

8. Certificate for Physically Challenged Attested True Copy

9.

10.

11.
8. Other Information Section :
Mother Tongue
Employment Status Employed/ Unemployed Do you wish to join NCC NSS

Would you like to apply for Hostel :

Hobbies, Proficiency and other interests :

Games and sports participation Level :

(e. q. College / State / National / International etc.)

Personal identification Marks : 1. 2.

9. Declaration by Student :

I hereby declare that I have read the rules related to admission and the informaion filled in by me in this form is accurate and true to the
best of my knowledge, I will be responsible for any discrepancy, arising out of the form signed by me and I undertake that, in absence of
any document the final admission will not be granted and or admission will stand cancel.

I am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that I will abide by all the rules and regulations of the said Act.

Place :

Date : Signatue of the Student

10. Declaration by Guardian :

I have permitted my son/daughter/.ward to join your college. The information supplied by him/her is correct to the best of my knowledge.
I have acquainted myself with the rules and fees, dues to my son/daughter/ward and to see that he/she observes.

Place :

Date : Signature of the Guardian

11. For College / Institute USE Only.

Designation Remarks / Particulars / Recommendations Signature and date

Admission Clerk
Admission Committee Cash Received : Rs. Receipt No.
Accountant / Cashier
Register / Office
Superintendent
Principal / Director