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Application Form 
Printed on 11/12/2014 1:36:51 PM Free Ship , 2014-2015 
Diploma in Engineering 
(Mechanical) 
Course 
Application Number 
Application type 
APPA3252904M20132014 
Renewal 
Renewal Course Year N.A 
Student SSC Details 
SSC Board 
Passing Year 
Vimukta Jat Nomadic Tribes 
MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 
2013 SSC Seat No A325290 SSC Marks Obtained 88.55 
Applicant's Details 
Applicant Name SACHIN RAJESH CHAKOR Mother's Name SUNITA 
Date of Birth 29-11-1997 Gender Male Is Resident of Maharashtra Maharashtra 
Application Date 12-11-2014 Caste Category Vimukta Jat Nomadic Tribes 
Sub Caste 
Caste Vanjari (30) 
Marital Status No 
Orphan No Is Disabled No Disability Type N.A. 
Is Applicant Salaried ? NO Applicant's Annual Income 0.00 Total Annual Income 342699.00 
Do You Want To Apply for Goverment Hostel? No Currently staying Hostel Category N.A 
Student Prequalifying Details 
Academic Year Institute Course Course Year Percentage Result 
2013 - 14 Government polytechnic Mumbai Diploma in Engineering 
2012 - 13 avm high school SSC 1 88.55 Pass 
2011 - 12 avm high school 9th Standard 1 68.00 Pass 
Institution Details 
(Mechanical) 
1 70.00 Pass 
Name of School/College/Institute where Admitted Principal,Government Polytechnic,Bandra(E),Mumbai-51 
Course Name 
Diploma in Engineering (Mechanical) 
EID Number UID Number 
Subject 
N.A 
CAP Number N.A 
College Adm.No 0613089 Joining Date 20-08-2014 
Is Fees Paid ? No Fee Paid 0.00 Fee Receipt No. 
Fee Receipt Date N.A 
Course Year 2 
Quota Government Quota 
GrantType Granted 
Is Admission after Diploma? No 
Contact Details 
Residential Number: 9004489950, MobileNumber: 9967129595, EmailAddress: sachinchakor3@gmail.com 
Address For Correspondence 
Address:- Location:- chakor chawl pratap nagar City:- village Pincode:- 400097 Taluka:- Mumbai(Suburban) District:- Mumbai 
(Suburban) 
1 Of 2
Parent / Guardian Details 
Parent's name RAJESH MARUTI CHAKOR 
Relation with Applicant Father 
Hostel Information 
Is Staying at Hostel ? No Has Applied For Hostel ? No 
Name of Landlord / Hostel Hostel Admission Date 
Hostel Type Is Mess Service Available? No Rent Per Month 0.00 
Hostel/ Landlord Address 
Hostel/Landlord Contact Details 
Is Studying in night school? Yes 
Document Details 
Caste Certificate No MSC/SR/NT/109/200 
4 
District Issuing 
Office 
Mumbai (Suburban) Taluka Issuing 
Office 
Mumbai(Suburban) 
Caste Validity 
Certificate No 
N.A District Issuing 
Office 
N.A Scrutiny 
Committee No 
N.A 
Income Certificate No C/MHMSBO/8810/20 
13 
Issued in 2013 
University 
Registration No 
FS13ME015 
Student Bank Account Details 
Bank Name UNION BANK OF INDIA Bank Account No 318002010209985 
Branch Name MALAD (WEST) - MUMBAI IFSC Code UBIN0531804 MICR Code 400026024 
Document Attached 
Age 41(yrs) 
Profession Service 
Parmanent Address Location:- chakor chawl pratap nagar City:- village Pincode:- 400097 Taluka:- Mumbai(Suburban) 
District:- Mumbai (Suburban) 
Is Father Alive? Yes Annual Income 342699.00 
Declaration 
The information furnished by me is complete and correct. I bear the complete responsibility for all the above information. 
Applicant's Signature Applicant Parent's Signature 
Principal's Signature 
_______________________ _______________________ 
_______________________ 
2 Of 2

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lb1

  • 1. Application Form Printed on 11/12/2014 1:36:51 PM Free Ship , 2014-2015 Diploma in Engineering (Mechanical) Course Application Number Application type APPA3252904M20132014 Renewal Renewal Course Year N.A Student SSC Details SSC Board Passing Year Vimukta Jat Nomadic Tribes MAHARASHTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION 2013 SSC Seat No A325290 SSC Marks Obtained 88.55 Applicant's Details Applicant Name SACHIN RAJESH CHAKOR Mother's Name SUNITA Date of Birth 29-11-1997 Gender Male Is Resident of Maharashtra Maharashtra Application Date 12-11-2014 Caste Category Vimukta Jat Nomadic Tribes Sub Caste Caste Vanjari (30) Marital Status No Orphan No Is Disabled No Disability Type N.A. Is Applicant Salaried ? NO Applicant's Annual Income 0.00 Total Annual Income 342699.00 Do You Want To Apply for Goverment Hostel? No Currently staying Hostel Category N.A Student Prequalifying Details Academic Year Institute Course Course Year Percentage Result 2013 - 14 Government polytechnic Mumbai Diploma in Engineering 2012 - 13 avm high school SSC 1 88.55 Pass 2011 - 12 avm high school 9th Standard 1 68.00 Pass Institution Details (Mechanical) 1 70.00 Pass Name of School/College/Institute where Admitted Principal,Government Polytechnic,Bandra(E),Mumbai-51 Course Name Diploma in Engineering (Mechanical) EID Number UID Number Subject N.A CAP Number N.A College Adm.No 0613089 Joining Date 20-08-2014 Is Fees Paid ? No Fee Paid 0.00 Fee Receipt No. Fee Receipt Date N.A Course Year 2 Quota Government Quota GrantType Granted Is Admission after Diploma? No Contact Details Residential Number: 9004489950, MobileNumber: 9967129595, EmailAddress: sachinchakor3@gmail.com Address For Correspondence Address:- Location:- chakor chawl pratap nagar City:- village Pincode:- 400097 Taluka:- Mumbai(Suburban) District:- Mumbai (Suburban) 1 Of 2
  • 2. Parent / Guardian Details Parent's name RAJESH MARUTI CHAKOR Relation with Applicant Father Hostel Information Is Staying at Hostel ? No Has Applied For Hostel ? No Name of Landlord / Hostel Hostel Admission Date Hostel Type Is Mess Service Available? No Rent Per Month 0.00 Hostel/ Landlord Address Hostel/Landlord Contact Details Is Studying in night school? Yes Document Details Caste Certificate No MSC/SR/NT/109/200 4 District Issuing Office Mumbai (Suburban) Taluka Issuing Office Mumbai(Suburban) Caste Validity Certificate No N.A District Issuing Office N.A Scrutiny Committee No N.A Income Certificate No C/MHMSBO/8810/20 13 Issued in 2013 University Registration No FS13ME015 Student Bank Account Details Bank Name UNION BANK OF INDIA Bank Account No 318002010209985 Branch Name MALAD (WEST) - MUMBAI IFSC Code UBIN0531804 MICR Code 400026024 Document Attached Age 41(yrs) Profession Service Parmanent Address Location:- chakor chawl pratap nagar City:- village Pincode:- 400097 Taluka:- Mumbai(Suburban) District:- Mumbai (Suburban) Is Father Alive? Yes Annual Income 342699.00 Declaration The information furnished by me is complete and correct. I bear the complete responsibility for all the above information. Applicant's Signature Applicant Parent's Signature Principal's Signature _______________________ _______________________ _______________________ 2 Of 2