B. K.
BIRLA COLLEGE
OF ARTS, SCIENCE & COMMERCE, KALYAN
Conducted by Kalyan Citizen's Education Society
UDISE No: 27210600314 Index No: J 16.17.008
Application for Admission to XII SCIENCE - 1 (2024-2025)
Applicant's Personal Details :
Name of the Student : Surname First name Father's name Mother's Name
SONAR PRATHAMESH GAJANAN VARSHA
Student Name(MARATHI) ससननर PRATHAMESH GAJANAN
Gender : MALE Aadhaar card Number : 385340940067
Marital Status : UNMARRIED Blood Group : B+
Date of Birth : 06/03/2007 Place Of Birth : KALYAN
Birth Taluka : Kalyan Birth District : THANE DISTRICT
Birth State : Maharashtra Birth Country : INDIA
Nationality : INDIAN Caste Category : OBC
Religion : HINDU Sub Caste :
Caste : Sonar Physically Challenged : Not Applicable
Mother Tongue : MARATHI U-Dise of Previous Class : 27210603108
Stream : SCIENCE Weight (KG) :
Student's Saral Id : 4516449 Caste Category : OBC
Height(cm) :
Address for Correspondence(As per Aadhar Card):
Address : Triveni Park Building no.4, Khadakpada, Wayale Nagar, Kalyan
City/Town/Village : KALYAN (W) District : Thane
State : Maharashtra Pincode : 421301
Residential Area: Urban/Rural
Permanent/Native Address :
Address : Triveni Park Building no.4, Khadakpada, Wayale Nagar, Kalyan
City/Town/Village : KALYAN District : KALYAN
State : Maharashtra Pincode : 421301
Contact Details :
Student's Phone No: 9326850564 Student's Email Id: [email protected]
Parent's Phone No: 9137645784 Parent's Email Id:
Guardian's Phone No: Guardian's Email Id:
Parent's Details:
Name : GAJANAN
Office Address : Kurla Branch
Occupation : SERVICE Annual Income(Rs.) : 1,000,000.00
Sr.No. Subject Name Subject Type
Group Name : GROUP E (ET)
1 ENGLISH COMPULSORY
2 MATHEMATICS COMPULSORY
3 PHYSICS COMPULSORY
4 CHEMISTRY COMPULSORY
5 ENVIRONMENT EDUCATION AND WATER SECURITY COMPULSORY
6 PHYSICAL EDUCATION COMPULSORY
7 ELECTRONICS I OPTIONAL
8 ELECTRONICS II OPTIONAL
Declaration by Student
1.I hereby declare that I have read all the rules and regulations framed by the college authorities as given in college
prospectus, which are presently in force.
2.I hereby declare and undertake to abide by all the mentioned rules and regulations and hereby agree, if admitted,
to confirm to them and to such other rules as may hereafter be made for the smooth functioning of the college
3.I may not be granted terms or allowed to appear for the College/University Examination if my attendance in
lectures and tutorials/practicals falls short of 75 %.
4.I may not be granted any concession in any matter, if I take up any employment during the course of my studies.
5.I hereby declare that I shall show satisfactory progress and maintain good conduct.
6.I hereby declare that I have not registered my name at any other institution for any other full time course.
7.I hereby declare that the information 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 cancelled.
8.I WILL DISPLAY MY IDENTITY CARD PROMINENTLY IN THE COLLEGE PREMISES.
9.I have given my and my parents most recent contact details(Phone, Email). In case of any change I undertake to
inform college accordingly.
10.I hereby give my consent for use of my contact details for educational communication.
11.I am aware that as per University Circular No.SW/42 of 2015 dtd. 29th Oct. 2015, I am compulsorily required to
give and undertaking on www.antiragging.in & www.amanmovement.org
12.I will get myself enrolled for Voter ID card when i would turn 18 Years of age.
13.I am aware that if eligible for Scholarship/Freeship scheme of Social Welfare Department then I must complete
all the formalities in time. If I fail to do so then I undertake to pay full fees of course by end of October of the
Current Academic year.
14.I have read eligibility conditions of University of Mumbai for my course. My admission will be confirmed subject
to confirmation from University of Mumbai.
Date : 11/05/2024
Signature of the Student
Declaration by Guardian / Parent
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 of my son/daughter/ward and to see that he/she observes, the said rules in totality. I hereby give my
consent for use of my contact details for educational communication.
Date : 11/05/2024
Signature of the Guardian/Parent
Sr. No. Attached Documents and Certificates Original copy for upload Yes/No
1 AADHAR CARD 0 Attested copies YES
2 AADHAR CARD WITH ADDRESS 0 Attested copies YES
3 CASTE/CASTE VALIDITY CERTIFICATE 0 Attested copies YES
4 CLASS X MARKSHEET 0 Attested copies YES
5 CLASS XI MARKSHEET 0 Attested copies YES
6 LEAVING CERTIFICATE (SSC) 0 Attested copies YES
7 RATION CARD (FOR GIRLS ONLY ) 0 Attested copies NO
Note:
Attach the photocopy of the following documents and certificates:
1. For F.Y.J.C.(XI) Admission- Marksheet of SSC.
2. For S.Y.J.C.(XII) Admission- Marksheet of SSC & F.Y.J.C.(XI)
5. Caste Certificate & Caste Validity Certificate(if any).
6. Address Proof(Aadhar Card/ Passport/ Electricity Bill/ Telephone Bill).
