Roll No.____________________ Sr. No. ___________ SHRI VILE PARLE KELAVANI MANDAL’S DWARKADAS J. SANGHVI COLLEGE OF ENGINEERING (Affiliated to the University of Mumbai) PLOT NO.U-15, J.V.P.D.SCHEME, BHAKTIVEDANTA SWAMI MARG, VILE PARLE (W), MUMBAI – 400 056 TEL: 2610 7010 /2610 7461, FAX: 2619 4988 Affix latest Photograph of Size 4 cm x 3 cm APPLICATION FORM FOR ADMISSION TO FIRST YEAR B.E. DEGREE COURSE IN ENGINEERING FOR CANDIDATES BELONGING TO GUJARATI SPEAKING COMMUNITY (LINGUISTIC MINORITY) 2007-2008 Full Name : ________________________________________________________________________________________ (Block Letters) Surname First Name Father’s Name /Mother’s Name/Husbands Name Maiden Name Male /Female Single /Married *Seat No. MHT-CET2007 ________________________ * Merit No. MHT-CET2007________________________ AIEEE state Merit No.________________ (if any) AIEEE Score :____________________ (if any) MHT-CET 2007 H.S.C Marks Passed in Biology at H.S.C.(Tick) (√) S.S.C. Marks Maths Physics Chem Total out Of 200 Maths Physics Chem Total out Of 300 Yes No Maths Aggregate Marks Obtained Out of 200 300 (Attach attested copy of Statement of marks /Score Card and Leaving Certificate) Address of the Candidate _______________________________ Date of Birth: ______________________________ dd -mm – yyyy ____________________________________________________ Place of Birth ______________________________ ____________________________________________________ Race & Religion ___________________________ ____________________________________________________ Nationality _________________ Telephone (R ) ____________________ (Certificate Domicile/Leaving Certificate/Passport) Mobile No: _______________________________ Name & Address of the Institution for H.S.C. ___________________________________________________________ Name & Address of the Institution for S.S.C ____________________________________________________________ Note : If there is any break in studies the same should be explained. ___________________________________________ For office use only Other fees Receipt No. Date Amount Documents submitted Original /Undertaking Signature of the concerned Clerk Cashier’s Signature Date Reported Yes /No Course offered Officer’s Signature Course Accepted (Yes/No) Candidates Signature Fees Amount Receipt No. Cashier’s Signature P.T.O Proof: Candidate who belongs to Gujarati Speaking Community (Linguistic Minority) must submit the proof. Attach attested copy and original affidavit. Home Town (Native place) address: _____________________________ Name & residential address of Parent Or Guardian in full ______________________ __________________________________________________________ ______________________________________ ________________________________________________________ _______________________________________ Tel.No. & Mobile No. _____________________ Profession of Parent or Guardian along with professional address: __________________________________________________________________________________________________ __________________________________________ Tel. No.& Mobile No______________________________________ Annual Income of Parents or Guardian from all sources: ____________________________________________________ Declaration to be signed by the Candidate: I, ___________________________________________________________ declare that I have read all the Rules of Admission including those related with cancellation /refund of fees for the current year and on complete understanding these rules, I have filled in this form of application for admission for the current year. The information given by me in my application is true to the best of my knowledge and belief. I have not been debarred from appearing at any examination held by any Government constituted or Statutory examination authority in India. I fully understand that the offer of a course or branch of Engineering will be made to me depending on my merit inter-se and availability of a seat at the time of scrutiny of my application, when I will report to the admission authority according to the schedule of admission. I understand that no other document, other than attached to the application form, will be entertained for the purpose of claims /concessions, etc. in connection with my admission. I hereby agree to conform to any rules, acts and laws enforced by Government and the University and I hereby undertake that so long as I am a student of the college, I will do nothing either inside or outside the college which may result in disciplinary action against me under the rules, acts and laws referred to Rule. I fully understand that the Principal of the college will have full liberty to expel /rusticate me from the college for any infringement of the Rules of Conduct and Discipline referred to and the rules of conduct and discipline prescribed by the college /University (if any) and the undertaking given above. I am enclosing herewith the following list of documents :-(tick) 1. Admission Processing Fee Receipt (Original) 2. SSC Mark-sheet (Attested Photocopy) 3. *HSC Mark-sheet (-do-) 4. MHT-CET2007 Mark-sheet (Photocopy) 5. Leaving Certificate after passing H.S.C. (Attested Photocopy) 6. Certificate of Indian Nationality of Candidate (-do-) 7. Affidavit of belonging to Gujarati Speaking Community (Linguistic Minority) (Original & Attested Photocopy) 8. Proof of belonging to Gujarati Speaking Community (Linguistic Minority) (Attested Photocopy) *Provisional Eligibility of Mumbai University (For other than Maharashtra H.S.C. Board candidates). I hereby give an undertaking that I will abide by the rules and regulations of the college in force as at present and as may be amended from time to time. Place & Date: ________________________________ (Signature of Candidate) Declaration to be signed by the Parent /Guardian: I, ___________________________________________________________________________________, declare that the particulars furnished by my son /daughter /ward in this application form are correct to the best of my knowledge. I undertake and bind myself to pay on behalf of my son /daughter /ward such fees, charges, etc. which the Government of Maharashtra /University /Competent Authority may approve /levy from time to time by due date and in the event of failure on my part and /or on the part of my son /daughter /ward, the Principal of the college may take such action against my son /daughter /ward, as he may deem fit. _______________________________ Place& Date (Signature of Parent/Guardian) FORMAT -A The candidates who belongs to Gujarati Speaking Community (Linguistic Minority) Form of affidavit to be made by the candidate who has completed 18 years of age on a stamped paper of Rs. 100/-(Rupees One Hundred only) before a Notary or an Executive Magistrate or a Metropolitan Magistrate. A F F I D A V I T I, _______________________________________________________________________________, an Indian inhabitant, residing at _________________________________________________________________________________________ __________________________________________________________________________________________________ son /daughter of Mr. ________________________________________________________________________________ an Indian inhabitant, residing at ________________________________________________________________________ __________________________________________________________________________________________________ do hereby solemnly affirm and say that I belong to the Gujarati Community which is a linguistic minority in the State of Maharashtra. Solemnly affirmed at ____________________________________ this _____________________________________ day of ____________________________________________ 2007. Identified by _______________________________________ (Signature of candidate) __________________________ Before me _______________________________________ __________________________________________________________________________________________________ FORMAT -B Form of affidavit to be made by the father /mother /guardian of the candidate who has not completed 18 years of age on a stamped paper of Rs. 100/-(Rupees One Hundred only) before a Notary or an Executive Magistrate or a Metropolitan Magistrate. A F F I D A V I T I, _______________________________________________________________________________, an Indian inhabitant, residing at _________________________________________________________________________________________ __________________________________________________________________________________________________ father/mother/guardian of Mr. /Miss ____________________________________________________________________ aged _____________________________ years and ________________________________________ months, and Indian inhabitant, residing at ________________________________________________________________________________ __________________________________________________________________________________________________ do hereby solemnly affirm and say that my son /daughter /ward belongs to the Gujarati Community which is a linguistic minority in the State of Maharashtra. Solemnly affirmed at ____________________________________ this _____________________________________ day of ____________________________________________ 2007. Identified by _______________________________________ (Signature of father /mother /guardian __________________________ of candidate) Relationship to the Candidate : _____________________________ Before me _______________________________________