MODEL COLLEGE (EMPOWERED AUTONOMOUS) College Code:
MCA
Kanchangaon, Khambalpada, Near R. B. T. School, Thakurli,
Dombivli (E), 421 201 Application No.:
FYBCOM/627
For College use Course Applied For: FYBCOM Registration No.
only 3946982
Medium:
Registration Date: 20/07/2025
1. Personal information section
Last Name First Name Middle Name
Name of Student GAUD ANKIT ATMARAM
Father's Name
Mother's Name: GAYATRIDEVI In-House Student: NO
Marital Status: UNMARRIED Saral No.:
Date of Birth: 08/11/2008 Gender: MALE
Place of Birth: DEORIA Blood Group: O+
Grandfather's Name: Native Place: DEORIA
Voter ID card No.: Organ Donor: NO
Bank Name: Account No.: Transaction Type: ONLINE
Religion: HINDU Nationality: INDIAN UDISE No.
Aadhaar card No.: 380511511913 Driving Licence No.: Eligibility No.:
ABC Id: 848302704922 Is Orphan: NO
Orphan Category: 0 Culturaral Activities:
2. Address Details
Address of Correspondence: KALYAN SHIL ROAD ,GOLAVLI,KALYAN DOMBIVALI EAST Pin Code: 421203
State: MAHRASHTRA District: THANE Tehsil: City:
Permanent Address: KALYAN SHIL ROAD ,GOLAVLI,KALYAN DOMBIVALI EAST Pin Code: 421203
State: MAHRASHTRA District: THANE Tehsil: City:
3. Contact Details
Student Mobile No.: 9326582591 Alternate Contact Number:
Student Email Id: ANKITGAUD7771@GMAIL.COM Parent phone: 9699183563
4. Legal Reservation Information Section
Domicile state: Admission Category: OPEN Caste Category: OPEN
Caste: OPEN Phy. Handicapped:
Caste Certificate No.: Learning Disability No.:
5. Social Reservation (Special Category) Information Section
SR No. SOCIAL RESERVATION NAME
6. Education Details Section
Name of Name of Date of Examination Passing Grade/Total Obt.
Name of Board % CGPA
Examination school/College Passing Seat Number certificate No. Marks Marks
MAHARASHTRA
HSC R.T.P. HIGH SCHOOL 15/04/2025 600 287 47.83 0
STATE BOARD
MAHARASHTRA F.F KN DUBEY HIGH
SSC 10/05/2023 500 256 51.2 0
STATE BOARD SCHOOL
7. Qualifying Exam Details Section
QUALIFYING EXAM NAME: SSC
College/School Admission Passing Marks Total Education
Board/university Percentage Place Arts/Com/Sci Percentile
Attended Year Year Obt. Marks Gap
F.F KN DUBEY HIGH MAHARASHTRA STATE
0 2023 256 500 51.2 NO 0
SCHOOL BOARD
Qualifying Exam Subject Details
Sr. No. Subject Name Total Marks Obtained Marks
8. Subject Details Section
Sr. No. Group Name Subject Name
9. Attached Documents
Sr No. Name of Documents/Certificate
1 SSC/10TH MARKSHEET
2 HSC/12TH MARKSHEET
3 UNIVERSITY PRE-ADMISSION FORM
4 AADHAR CARD
10. Guardian / Parent Information Section
Guardian's/ Parent's Name:
Occupation of the Guardian/Parent: Annual Income of the guardian/Parent:
Relationship of Guardian with applicant: -- Guardian/Parent Phone No.: 9699183563
11. Other Information Section
Mother Tongue: HINDI Employment Status: NO Do you wish to join NCC / NSS: NO
Would you like to apply for Hostel: NO
Hobbies, Proficiency and Other interests: NA
Games and sports participation:
Identification Mark 1: Identification Mark 2:
12. Declaration by Student
I hereby declare that, I have read the rules related to admission and the information
filled in by me in this form is accurate and true to the best of my knowledge. I will be responsible for any
discrepancy, arising out of the form signed by me and I undertake that, in absence of any document the
final admission will not be granted and/or admission will stand cancel.
Place:
Date:
Signature of Student
13. Declaration by Guardian / Parent
I have permitted my son / daughter / ward to join your college. The information
supplied by him / her is correct to the best of my knowledge. I have acquainted myself with the rules and
fees, dues to my son/daughter/ward and see that he/she observes.
Place:
Date: Signature of the Guardian/Parent
14. For College / Institute Use Only
Designation Remarks / Particular / Recommendation Signature and Date
Admission Clerk
Admission Committee
Accountant / cashier
Registrar/Office superintendent
Transaction Details Payment Mode: ONLINE Cash Received: 200 Transaction ID.: E2507250JQ53ZD
REMARK OF THE ADMISSION COMMITTEE
May be admitted to Class__________________________________________________________________ Section___________________________
May be Rejected_______________________________________________________________________________________________________________
Last date of payment of fees___________________________________________________________________________________________________
Admission may be cancelled if the fees are not paid by this date.
Principal Signature of Admission Committee
Date:
Print Date : 25/07/2025
