Jagdamba Education Society's S.N.D. POLYTECHNIC Babhulgaon, Yeola, Tal-Yeola, Dist-Nashik-423401 Approved by-allidia Technical Education Couneil (AICTE), New Delhi GE Directorate of Technical Education{O18) Murhoby ee | Afflioted to -Maharashtra State Board of Technical Education (MSBTE), Mumbai PROVISIONAL ADMISSION FORM Academic Year: S lCourse/Programme Civil Engineering Computer Engineering Electrical Engineering Mechanical Engineering Attach Passport Size Photo Here URS LaSoLL) Name of Student Name of Father/. Guardian Name of Mother Correspondence: Address Permanent Address Mobile Number (Self) Mobile Number (Parent) Religion Category Caste Email-idAcademic Details Qualification] Subject Year | Board/University | Marks in % ssc Lore of Marks in Qualifying Examination Subject Maximum Marks | Marks Obtained | Marks in % Physics Chemistry Mathematics Other da) EL cea Seed Physically Handicapped: YES; | NO | Type of Physical Disability! || |[ jf |) ||| LL) BloodGroup| | ||| TLS ali Soc atten sSC Marksheet [ | Cast Validity Certificate HsC Marksheet [| Domicile Certificate O School/College Aadhar Card (Photocopy) Leaving Certificate |! — Income Certificate[ | | Bank Aadhar Linking a ce (Photocopy) Lt Cast Certificate Non-creamy Layer-— Bank Passbook _ Certificate (Photocopy) Signature of Student/GuardianSa Jagdamba Education Society's S.N.D. POLYTECHNIC ) Babhulgaon, Yeola, Tal-Yeola, Dist-Nashik-423401 A approved by-All india Council of Technical Education (AICTE), New Delhi Directorate of Technical Education(OTe), Mumabt AYfliated to-Maharashtra State Board of Technical Education (MSBTE), Mumba aaa -S/oD/o_. Permenant Address Mobile Number do hereby undertaken that the particulars admitted to the college are true and cor- rect. | agree that the admission is granted to me as per terms and conditions of the institution. | also understand that admission will be cancelled and fee paid by me will be fortfeited if any of the particulars given by me at the time of admission or later on are found to be incorrect or false. 2. understand that the student association, active or passive with any unlawful organi- zation, union etc. are forbidden. i shall not have objection if i expelled or resticated from the college/ institute due to my participation in such union, unlawful activity. 3.1 understand that consumption of alcohol, drugs or any intoxicant and smoking within the college/institute/hostel premises is forbidden. 4, | hereby declare that | was never involved or punished in any case of indiscipline and unlawful activity during my school or college career. 5. | also know that in case of discontinuation of my studies or leaving the college/insti- tute in between duration of my course | shall have to pay the fee for remaining dura tion of course. lunderstand that the student once admitted to the institute/college is not eligible for transfer to any other college and there will be no refund of fee in such cases as men tioned. 7.1 understand that in event of breach of any of the above mentioned conditions of the undertaking, my admission will stand cancelled without any obligation on the part of the college/institute to issue show cause notice . The fee paid shall be forfeited. ‘CLARATION hereby solemnly affirm & declare that | have understood the points, rules and regula~ tions mentioned in the undertaking. further confirm that the information given in the ap- plication form is correct and true to the best of my knowledge & belief. Date: Place: Name and signature of Student Name and signature of Parent/Guardian