Form No.

ChandralopShlkWn PTow.& MAn<W! (Reg No.MH / 6003/ 7-2-2001)

Colege of Fte EnglneeriJg And Safety Management

CMndraJop UmpuJ, Gut No.52, ShlwN, twsul-Sawang!,

Jolgaon Road. AIA- - 431008. E mall:desm.aur.com

Name of the Cand date . _

(Ao on 11r Cwtlllclto)

Wish lo apply for Two Year I One Year I 6 Months Coursein

Falhet's Name :

.Mothe(s Name

Occupation : MobRe Number Data ol Birth Blood Groop : sex : _..Nationality BankAcc:ount No : IFSC COOE : _

Bank Name : Aadhaar card No.

Caste : e Mal=

Addraaa for Comispondenca :

District : State : PIN Ph. No.: (STD Code) Number : Mobile :

Permanent Address :

Educational Quallllcallons : Hosle! Required :Yes D NoD

Std.

Name of the Sci-' I Collage

Yaar ol

Pasalr111

Unfvorsity

/ Board

Malit

ObtalrMd

OUt Of

% of Mailts

x

XII

B.ScJDlpJ Degree

Ihereby declare lhat theinformation givenIn application form Is correct lo lhe best of my knowledge and belief Place : _

Date : / 201

For office use only

Slgnalure of Student Signalure of Parent

Course:. FinalFees Fees PaidAmount:. _ DO No. Drawn on Bank

Authorised Signatory

Admission Form

Contact this candidate