STUDENT COPY

SUSHILADEVI KANYA MAHAVIDHYALAY (71153) Application No :

Hatkanangale
Academic Year: 2018-2019 841482
YCMOU Study Center Submission Slip Distance Education

Instruction:
Please submit copy of this submission slip with following list of document to Study Center for Recommendation of
Program for Admission and/or Recommendation of Scholarship.
Please note that application shall be considered for admission only after recommendation by study center
If recommendation by study center not completed before last date of admission your application will be automatically
cancelled. Please note that university will not refund the fees in case of rejection by study center for want of Eligibility.

Course Applied for : B.A.(with Credits) - Distance Education - 2000 Pattern - S.Y.B.A. (G01) PRN:
Application Date : 11/10/2018
Exam Center Name [Code] : - [-]
1.Personal Information
Candidate's Name(Regional) : मुळे सुजाता वीण
Candidate's Name as printed on MULE SUJATA PRAVIN
School leaving/Passing Certificate : [*This name will appear on all University records/documents]
Father's/Husband's Name : PRAVIN MULE Mother's Name : KANCHAN
Marital Status : Married Mother Tongue : Marathi
Place Of Birth : PETH VADGAON Gender : Female Date Of Birth (DD/MM/YYYY) : 27/12/1979
Blood Group : Religion : Hindu Country of Citizenship : India
Height : Not Available Weight : Not Available Hemoglobin : Not Available
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
City/Town/Village : AT
State : Maharashtra District : Kolhapur Tehsil : Hatkanangale Location Area : Rural
POST PETH VADGAON
Address (House
no,street/area/suburb VILAS KUDALKAR AT POST PETH VADGAON Pin Code : 416112
etc.) :
Permanent Address :
City/Town/Village : AT
State : Maharashtra District : Kolhapur Tehsil : Hatkanangale Location Area : Rural
POST PETH VADGAON
Address : VILAS KUDALKAR AT POST PETH VADGAON Pin Code : 416112
Contact details
Mobile
9594980456 Email ID: sujatapmule@gmail.com
Number
2.Legal Reservation Information
Category Type : Open Category : GEN
Is Specially Abled? No
3.Social Information(Additional Inforamtion)

Paper Selected for:

S.Y.B.A.
MAR210 - Vangmayprakarancha Aabhyas MAR211 - Swatantryottar Vangamayen Pravah
PSY216 - Me Aani Maze Vartan PSY217 - Balsangopan Aani Balvikas
SOC222 - Samajik Parivartan Aani Samajik Chalvali SOC223 - Bharatiya Samaj
EVS201 - Enviorment Studies
T.Y. B.A.

Medium of Instruction : Marathi

Proof of Date Of Birth (Addhar Card, PAN card, School Leaving, Driver’s license)
Statement of Marks of Qualifying Exam (पा ता परी ेची गुण प का)
Passing Certificate of Std 12th / Statement of Marks of Std 12th.
Affidavit for changed name/ Marriage Certificate / Govt. Gazette.
Admission Fee Payment Details Payment Status : Paid Transaction Date : 13/10/2018
Transaction Number :
Fee Category : Direct/Credit Transfer Admission Transaction Type : Online Payment
8414821539430749017
Admission Late Fee - 100 Admission Super Late Fee - 500
Adm Exam Fee - 700 Tution Fee - 1600
Registration Fee - 100 Development Fund Fee - 450
Other Fee - 150 Total : 3000
4.Guardian Information
Occupation of Guardian : Business Annual Income of Guardian : 100000
5.Educational Details
Name of Month and Exam
Name of Name of Certificate Mark Out
Board/University and Year of Seat CGPA %
Examination School/College No. Obtained Of
State of University Passing No.
DR BABASAHE
Certificate : Shivaji December
AMBEDKAR COLLEGE 64 063327 259.00 600.00 -- - -- 43.17
F.Y.B.A. University,Maharashtra 1998
PETH VADGAON
Your Last Qualifying Exam: F.Y.B.A.
7.Other Information
Would you like to apply for Hostel accommodation required NA
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
MULE SUJATA PRAVIN, Application No : 841482
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 Signature and
Remarks / Particulars / Recommendations
Date
Admission Clerk
Admission
Committee
Accountant/Cashier Cash Received: Rs. Receipt No.: Date:
Registrar/Office
Superintendent
Document printed on Sat Oct 13 2018 11:51:17 GMT+0530 (India Standard Time)
[STUDY CENTER COPY]

SUSHILADEVI KANYA MAHAVIDHYALAY (71153) Application No :

Hatkanangale
Academic Year: 2018-2019 841482
YCMOU Study Center Submission Slip Distance Education

Instruction:
Please submit copy of this submission slip with following list of document to Study Center for Recommendation of
Program for Admission and/or Recommendation of Scholarship.
Please note that application shall be considered for admission only after recommendation by study center
If recommendation by study center not completed before last date of admission your application will be automatically
cancelled. Please note that university will not refund the fees in case of rejection by study center for want of Eligibility.

Course Applied for : B.A.(with Credits) - Distance Education - 2000 Pattern - S.Y.B.A. (G01) PRN:
Application Date : 11/10/2018
Exam Center Name [Code] : - [-]
1.Personal Information
Candidate's Name(Regional) : मुळे सुजाता वीण
Candidate's Name as printed on MULE SUJATA PRAVIN
School leaving/Passing Certificate : [*This name will appear on all University records/documents]
Father's/Husband's Name : PRAVIN MULE Mother's Name : KANCHAN
Marital Status : Married Mother Tongue : Marathi
Place Of Birth : PETH VADGAON Gender : Female Date Of Birth (DD/MM/YYYY) : 27/12/1979
Blood Group : Religion : Hindu Country of Citizenship : India
Height : Not Available Weight : Not Available Hemoglobin : Not Available
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
City/Town/Village : AT
State : Maharashtra District : Kolhapur Tehsil : Hatkanangale Location Area : Rural
POST PETH VADGAON
Address (House
no,street/area/suburb VILAS KUDALKAR AT POST PETH VADGAON Pin Code : 416112
etc.) :
Permanent Address :
City/Town/Village : AT
State : Maharashtra District : Kolhapur Tehsil : Hatkanangale Location Area : Rural
POST PETH VADGAON
Address : VILAS KUDALKAR AT POST PETH VADGAON Pin Code : 416112
Contact details
Mobile
9594980456 Email ID: sujatapmule@gmail.com
Number
2.Legal Reservation Information
Category Type : Open Category : GEN
Is Specially Abled? No
3.Social Information(Additional Inforamtion)

Paper Selected for:

S.Y.B.A.
MAR210 - Vangmayprakarancha Aabhyas MAR211 - Swatantryottar Vangamayen Pravah
PSY216 - Me Aani Maze Vartan PSY217 - Balsangopan Aani Balvikas
SOC222 - Samajik Parivartan Aani Samajik Chalvali SOC223 - Bharatiya Samaj
EVS201 - Enviorment Studies
T.Y. B.A.

Medium of Instruction : Marathi

Proof of Date Of Birth (Addhar Card, PAN card, School Leaving, Driver’s license)
Statement of Marks of Qualifying Exam (पा ता परी ेची गुण प का)
Passing Certificate of Std 12th / Statement of Marks of Std 12th.
Affidavit for changed name/ Marriage Certificate / Govt. Gazette.
Admission Fee Payment Details Payment Status : Paid Transaction Date : 13/10/2018
 Transaction Number :
Fee Category : Direct/Credit Transfer Admission Transaction Type : Online Payment
8414821539430749017
Admission Late Fee - 100 Admission Super Late Fee - 500
Adm Exam Fee - 700 Tution Fee - 1600
Registration Fee - 100 Development Fund Fee - 450
Other Fee - 150 Total : 3000
4.Guardian Information
Occupation of Guardian : Business Annual Income of Guardian : 100000
5.Educational Details
Name of Month and Exam
Name of Name of Certificate Mark Out
Board/University and Year of Seat CGPA %
Examination School/College No. Obtained Of
State of University Passing No.
DR BABASAHE
Certificate : Shivaji December
AMBEDKAR COLLEGE 64 063327 259.00 600.00 -- - -- 43.17
F.Y.B.A. University,Maharashtra 1998
PETH VADGAON
Your Last Qualifying Exam: F.Y.B.A.
7.Other Information
Would you like to apply for Hostel accommodation required NA
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
MULE SUJATA PRAVIN, Application No : 841482
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 Signature and
Remarks / Particulars / Recommendations
Date
Admission Clerk
Admission
Committee
Accountant/Cashier Cash Received: Rs. Receipt No.: Date:
Registrar/Office
Superintendent
Document printed on Sat Oct 13 2018 11:51:17 GMT+0530 (India Standard Time)