MAHARASHTRA STATE BOARD OF SECONDARY & HIGHER SECONDARY EDUCATION, PUNE 411 04
APPLICATION FOR ADMISSION TO S.S.C. EXAMINATION OF FEB-MAR/SEP-OCT 20……
1 School Index No. 2 Appl.Sr.No
3 Centre No.
4a Last Name CANDIDATE ‘S
PHOTO
b First Name
c Middle Name
d Mother's Name
Residential
5
Address
SIGNATURE OF CANDIDATE
6 Date Of Birth
7 Gender 1) Male O 2) Female O
If Belongs to
8
Minority Religion 0) Non-Min O 1) Muslim O 2) Christian O 3)Buddhist O 4) Sikh O 5) Parsi O 6) Jain O
9 1) SC O 2) ST O O
3) VJ(A) 4) NT(B) O 5) NT(C) O 6) NT(D) O
Caste
7) OBC O 8) SBC O 9) OPEN O 10) MARATHA (ESBC) O O 11) MUSLIM (SBC-A)
Handicapped or Not 0) No Handicapped O 1) Blind O 2) Deaf O 3) Dumb O
10
Handicapped 4) Orthopedically Handicapped O 5) Spastic O 6) Learning Disable O 7) Autism O
Medium of 1) English O 2) Marathi O 3) Gujarati O 4) Kannada O 5) Urdu O
11
Instruction 6) Sindhi(Arabic/Devnagari) O 7) Telugu O 8) Hindi O
A 1) Fresh O 2) Repeater O
B 1) Regular O 2) Private O 3) Isolated O 4) Class Improvement O
Category of
12
Candidate C 1) Exempted O 2) Non Exempted O
D Whether Pre-vocational 1) Yes O 2) No O
E Whether foreigner 1) Yes O 2) No O
13 Subject Details
Lang *Exempted Subject Information
Sr. Subjects of
No. Ans (Previously Passed Subjects in which candidate widh to claim exemption
Name Code code Seat No Month Year Marks Obt
st
1 1 Language Feb O Oct O
nd
2 2 Language Feb O Oct O
rd
3 3 Language Feb O Oct O
4 Mathematics Feb O Oct O
5 Science & Technology Feb O Oct O
6 Social Sciences 7 3 Feb O Oct O
7 ICT 4 1 Feb O Oct O
8 Pre-Vocational Feb O Oct O
9 Grade Sub (for Handicapped) Feb O Oct O
NOTE: 1) Please write 9 in case of exemption of column ‘Lang of Ans code’ and provide information in column under
‘Exempted Subject Information’
2) The handicap candidate offering special subject/s from the GRADE SUBJECTS group can only write their
code in the respective box and no need to circle corresponding BUBBLE (O) for the subject
14 Total No. of Exemption Claimed
15 Enrollment Certificate No.(Private Candidate) 1)FEB O 2)OCT O Year Enrollment No.
16 Last Exam Seat No. 1)Mar O 2)Oct O Year Seat No
(१) मी खाल सह करणार मा
यमक शालात माणप परा माच/सट बर २०..... वेश अज करत
17 Undertaking by Candidate/Head of Institution
आहे . मंडळाने वेळोवेळी &नगमत केलेले सव &नयम आ)ण सुचनांचे पालन कर+यास माझी सहमती
(i) I the undersigned hereby apply for the admission to the SSC EXAM March/September 20…… I
agree to abide by the regulations and all instructions issued by the Board time to time. I am aware of आहे . शासनाने माय केले-या मंडळा.या परा व /यासंबंधी.या 1वषययोजना याची मला मा3हती आहे
the scheme of subject combination and examination of the Board approved by the Government and I आ)ण मी चुक4ची 1वषययोजना &नवडल असेल तर /या 1वषयांची संपदणूक र7 कर+यासंबंधीचा
agree to abide by the decision of the Board to treated the performance of the subject as cancelled if मंडळाचा &नणय माझेवर बंधनकारक असेल. (२) उमेदवारासाठ:.या सूचनांचे प मला ात झाले असून
wrong combination of subjects if offered. (ii) I have received a copy of the INSTRUCIONS TO THE
CANDIDATE and undertake to abide by them (iii) I have received a receipt of the EXAMINATIO ते मा;यावर बंधनकारक राहल. (३) सं<था मुखांकडू न मला आवेदनपाची आ)ण परा शु-काची
FORM and EXAM.FEE from the Head of the Institution. (iv) I HAVE NOT PASSED S.S.C. पोहोच पावती ात झाल आहे . (४) मी यापुव> कधीह महारा?@ राAय मा
यमक व उ.च मा
यमक
Examination conducted by the Maharashtra State Board of Secondary & higher Secondary Education शण मंडळाने घेतलेल मा
यमक शालात माणप परा Cकं वा इतर कोणतेह वैधा&नक मंडळ
or any other equivalent Examination (other than those appearing for Isolated Subject/class यांची इतर कोणतीह समतु-य परा (Fेणी सुधार/तुरळक 1वषय घेवून 1व?ठ 1व7ाGयाHIय&तरJत)
Improvement) of any statutory Board.
उ/तीण झालेल/झालेलो नाह.
Place Date : Signature of Candidate <थळ: 3दनांक: उमेदवाराची <वार
(i) I hereby certify that the information given by the candidate has been verified by me and is found (१) उमेदवाराने 3दले-या मा3हतीची मी पडताळणी केल असून ती बरोबर अस-याची खाी कKन
to be correct. (ii) I certify that a receipt of EXAMINATION FORM and FORM FEE along with the मा)णत करत आहे . (२) आवेदनप व परा शु-क आ)ण उमेदवारासाठ:.या सूचनांची पोहोच मी
INSTRUCTIONS TO THE CANDIDATE have been given to the candidate. (iii) I certify that the
संबंLधत उमेदवाराला 3दल आहे . (३) मंडळा.या &नयमांनुसार उमेदवार उ.च मा
यमक शालात
candidate is eligible to appear for H.S.C. exam as per Boards regulations.
माणप परा 1व?ठ हो+यास प अस-याचे मी मा)णत करत आहे .
Signature and Seal of the Head of the Institution मुयायापकाची वार व शाळे चा शका
PDBEDP/APPLICATIONS/HAPPL_SSC_M15.PDF
