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Photograph
Appitca.t.ion...Numbef
Application type

Renewal Course _Year

Student SSC Details

SSCL&ealUa

Year

SSC

Applicant's Details
Name

MifflliiLiJlJMI

tS-JDMifated.
Aoolicant's
ts Stavlno

Total Annual Income

Has Applied For Hostel ?

Institute

Academic Year

Exam

Result

institution Details
where Admitted
Coy rsa Name

Is Fees. Paid ?
Course Year
Contact Details

....

,.:

. ; . : /

ResidenBal Number., MobileNurnber: , EmaiiAddress.

Address For Correspondence
Address:- Location:- City;- Ptncode:- 0 Taluka> Distnct:-

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Parent /Guardian Details

Parent*s name

Jflt

nanenl. Address
An.ny.9l Income

l&EaMier.Aiivf.Hostel Information

Qate
Is Mess...S.efvi.ce Available?
Hotted Landlord

Doeument Details

Caste Certificate No

income Certificate
No

Issuedin

Registration No

Student Bank Account Deteils

Bank Name

Baok.
Account No

IFSC Code

MICRCade

Document Attached
Declaration

illiilj 11

| [

The information fyrntshed by me is complete and correct. I bear the complete responsibility for all the above
information.
Applicants Signature

Applicant Parenfs Signature

Principal's Signature

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