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Application No: Regular

This document is an application form for a B.Voc. program in Cyber Security and Forensics at Birla College of Arts, Science and Commerce. It contains personal information about the applicant such as name, date of birth, address, guardian details, educational qualifications, program details, and a declaration signed by the applicant. The form also has sections for official use by the college such as admission remarks, cash payment details, and registrar recommendations.

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manoj phadtare
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
962 views2 pages

Application No: Regular

This document is an application form for a B.Voc. program in Cyber Security and Forensics at Birla College of Arts, Science and Commerce. It contains personal information about the applicant such as name, date of birth, address, guardian details, educational qualifications, program details, and a declaration signed by the applicant. The form also has sections for official use by the college such as admission remarks, cash payment details, and registrar recommendations.

Uploaded by

manoj phadtare
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

10/26/21, 2:09 PM

For Office Use


Batch: Scrutiny Payment: Online/DD PI

Only Serial:

Birla College of Arts, Science and Commerce (23)

Birla College Road.


Kalyan
Application No :

University of Mumbai 2997167

M.G.Road, Fort, Mumbai-400032, Maharashtra(India)

Academic Year: 2021-2022


Regular
APPLICATION FORM

Course Applied for : B.Voc.(Autonomous)(with Credits) - Regular - CBCS - Cyber Security and Forensics - F.Y.B.Voc. PRN:
(Autonomous) Sem I 
(-)

Application Date : 26/10/2021 Payment Category :


1.Personal Information

Candidate's Name(Regional) : अन्सारी शाजान रिजवान

Candidate's Name as printed on Mark ANSARI SHAZAN RIZWAN


sheet : [*This name will appear on all University records/documents]

Father's/Husband's Name : RIZWAN ANSARI Mother's Name : TARANNUM


Marital Status : UnMarried Mother Tongue : Urdu
Place Of Birth : BHIWANDI Gender : Male Date of Birth (DD/MM/YYYY) : 03/10/2003
Blood Group : Religion : Muslim Country of Citizenship : India
Is Student NRI/ Foreign National : No Domicile State: Maharashtra
Address For Correspondence :
City/Town/Village :
State : Maharashtra District : Thane Tehsil : Bhiwandi Location Area : Urban
BHIWANDI
Address (House
HOUSE NO 12/3, GROUND FLOOR, BUDDHA WADA, BHIWANDI Pin Code : 421302
no,street/area/suburb etc.) :
Permanent Address :
City/Town/Village :
State : Maharashtra District : Thane Tehsil : Bhiwandi Location Area : Urban
BHIWANDI
Address : HOUSE NO 12/3, GROUND FLOOR, BUDDHA WADA, BHIWANDI Pin Code : 421302
Contact details
Mobile Number 7498150444 Email ID: ansarishazan444@gmail.com
2.Legal Reservation Information
Category Type :
Category : OBC Sub Category : JULAHA
Reserved
Is Guardian from EBC (Economic Backward
Is Specially Abled? No
Class)?  No
3.Social Information(Additional Inforamtion)

Paper Selected for:


Sem I
BVOCACSF101 - Paper 1 BVOCACSF102 - Paper 2
BVOCACSF103 - Paper 3 BVOCACSF104 - Paper 4
Sem II

BVOCACSF201 - Paper 1 BVOCACSF202 - Paper 2


BVOCACSF203 - Paper 3 BVOCACSF204 - Paper 4

Medium of Instruction : English


4.Guardian Information
Occupation of Guardian : Laborer Annual Income of Guardian : 0
5.Educational Details
Month
Name of Name of Board/University and State Exam Certificate Mark
Name of School/College and Year Out of CGPA %
Examination of University Seat No. No. Obtained
of Passing
MAHARASHTRA STATE BOARD THE SCHOLARS
OF SECONDARY AND HIGHER ENGLISH MEDIUM March
Std 10th A095987 -- 301.00 500.00 --
-
-- 60.20
SECONDARY HIGH SCHOOL AND 2019
EDUCATION,Maharashtra JR COLLEGE
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10/26/21, 2:10 PM

Month
Name of Name of Board/University and State Exam Certificate Mark
Name of School/College and Year Out of CGPA %
Examination of University Seat No. No. Obtained
of Passing
MAHARASHTRA STATE BOARD THE SCHOLARS
Std 12th OF SECONDARY AND HIGHER ENGLISH MEDIUM February
M022459 -- 443.00 600.00 --
-
-- 73.83
Science SECONDARY HIGH SCHOOL AND 2021
EDUCATION,Maharashtra JR COLLEGE
Your Last Qualifying Exam: HSC/Std 12th [Science]
7.Other Information
Would you like to apply for Hostel accommodation required NA
Required Documents and Certificates Section:
Passing Certificate of Std 12th / Statement of Marks of Std 12th OR Original Passing Certificate /Statement of Marks of Last Qualifying Exam like
degree,diploma,etc.

Certificate of Caste with Category.

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
Application No :2997167 (ANSARI SHAZAN RIZWAN)
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 Remarks / Particulars / Recommendations Signature and Date
Admission Clerk
Admission
Committee
Accountant/Cashier Cash Received: INR Receipt No.: Date:
Registrar/Office
Superintendent
Document printed on Tue Oct 26 2021 14:09:55 GMT+0530 (India Standard Time)

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