6/10/2017 ..::StateCommonEntranceTestCell,GovernmentofMaharashtra::..

FirstYearDegreeinEngineering/TechnologyAdmissions2017 ApplicationForm

STATECOMMONENTRANCETESTCELL
305,GovernmentPolytechnicBuilding,49,Kherwadi,Bandra(E),Mumbai400051(M.S.)

ApplicationFormforAdmissiontoFirstYearofUnderGraduateTechnicalCoursesinEngineeringandTechnologyforthe
AcademicYear201718

ApplicationID:EN17213130VersionNo:1
PersonalDetails
Candidate'sName MUKULSURESHSHENDE
Father'sName SURESH
Mother'sName MAMTA
Gender Male
DateofBirth 23/01/2000
CandidatureType MaharashtraTypeA
HomeUniversity RashtrasantTukadojiMaharajNagpurUniversity
Category SC
CategoryforAdmission SC
PersonwithDisability NotApplicable
DefenceType NotApplicable
AppliedforTFWSSeats No
MinorityCandidatureType No
DistrictfromwhichCandidatehasPassedSSC Nagpur
DistrictfromwhichCandidatehasPassedHSC/Diploma/B.Sc. Nagpur
ApplicationFeePaid(Rs . ) 600/ Nationality India
I,theholderofAadhaarNumber[326624206230],herebygivemyconsenttoStateCETCelltoobtainmy
AadhaarnumberforauthenticationwithUIDAI.StateCETCellhasinformedmethatmyidentityinformation
AadhaarNumber
wouldonlybeusedforadmissionpurposeandwillbesubmittedtoCIDRonlyforthepurposeof
authentication.
HasBankAccount? Yes
AccountNumber 7808001500002937 IFSCCode PUNB0780800
QualificationDetails
Qualification MarksObtained MarksOutOf Percentage
SSCMathematicsMarks 89.00 100.00 89.00
SSCScienceMarks 75.00 100.00 75.00
SSCEnglishMarks 88.00 100.00 88.00
SSCAggregateMarks 418.00 500.00 83.60
HSCPhysicsMarks 59.00 100.00 59.00
HSCMathematicsMarks 61.00 100.00 61.00
HSCChemistryMarks 45.00 100.00 45.00
HSCBiologyMarks 53.00 100.00 53.00
HSCEnglishMarks 71.00 100.00 71.00
HSCAggregateMarks 411.00 650.00 63.23
SSCBoard MaharashtraStateBoardofSecondaryandHigherSecondaryEducation,Pune
SSCPassingYear 2015 SSCSeatNumber J128317
QualifyingExam HSC HSCPassingStatus Passed
HSCBoard MaharashtraStateBoardofSecondaryandHigherSecondaryEducation,Pune
HSCPassingYear 2017 HSCSeatNumber N045507
MHTCET2017Details
AppearedforCET Yes RollNo MM4242406
PhysicsScore 17 ChemistryScore 21
MathematicsScore 34 TotalScore 72
JEE(Main)2017Paper1Details
AppearedforJEE Yes RollNo 15703789
PhysicsScore 16 ChemistryScore 0
MathematicsScore 9 TotalScore 25
ListofDocumentsRequiredatthetimeofDocumentVerificationandConfirmationatFacilitationCenter(Donot
attachXeroxCopies)
Sr.No. DocumentName
1. CertificateofIndianNationalityintheNameoftheCandidate.
2. SchoolLeavingCertificateoftheCandidateshowinghis/herPlaceofBirthintheStateofMaharashtra.
CasteCertificateclearlymentioningtheCategoryoftheCandidateandalsotheremarksthatthecasteis
3.
recognisedasbackwardclassintheStateofMaharashtra.
Caste/TribeValidityCertificateintheNameoftheCandidate,issuedbytheCaste/TribeValidityCommitteeof
4.
MaharashtraState.
5. StatementofMarksorCertificateofPassingSSC/EquivalentExamination.
6. StatementofMarksorCertificateofPassingHSC/EquivalentExamination.
7. ScoreCardofJEEMain(Paper1)2017.
8. CancelledChequeofBankAccount/1stPageofPassBook.
Declaration
IhavereadalltherulesofadmissionandonunderstandingtheseRules,IhavefilledthisApplicationFormforAdmissiontoFirstYearof
Under Graduate Technical Courses in Engineering and Technology for the Academic Year 201718. The information given by me in this
applicationistruetothebestofmyknowledge&belief.Ifatlaterstage,itisfoundthatIhavefurnishedwronginformationand/orsubmitted

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6/10/2017 ..::StateCommonEntranceTestCell,GovernmentofMaharashtra::..
falsecertificate(s),Iamawarethatmyadmissionstandscancelledandfeespaidbymewillbeforfeited.FurtherIwillbesubjecttolegaland/or
penalactionaspertheprovisionsofthelaw.
Place:Date:10/06/2017
PrintedOn:10/06/20178:10:18PM
LastModifiedOn:10/06/20178:06:05PM SignatureofApplicant
LastModifiedBy:EN17213130,49.35.5.78 (MUKULSURESHSHENDE)

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