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MHT-CET 2009. Grand Total (HSC). Phy., Chem. & Maths. Phy., Chem. & Bio. S.Y. D. Pharm. Marks obtained. Out of. RECENT. PHOTOGRAPH. OF CANDIDATE.
Sinhgad Technical Education Society’s

Smt. Kashibai Navale College of Pharmacy (SKNCOP) ( Approved by AICTE & Pharmacy Council of India & Affiliated to University of Pune ) 2006-07

Kondhwa-Saswad Road, Kondhwa(Bk), Pune - 411 048. INDIA, Tel: +91 - 20 - 2690 6166 / 65 Fax : +91 - 20 - 2693 1322, E-mail : [email protected], Web : FOR OFFICE USE ONLY (Not to be filled by Candidate) Regd. No. Received on Subject MHT-CET 2009 Grand Total (HSC) Phy., Chem. & Maths. Phy., Chem. & Bio. S.Y. D. Pharm.

Marks obtained

Out of


APPLICATION FOR ADMISSION TO FIRST YEAR / DIRECT SECOND YEAR DEGREE IN PHARMACY IN 2009 - 10 Notes : 1. Please fill the application form in full and block letters only. 2. Please strike out at asterisk mark* the unnecessary words, whichever is not applicable. 3. Please submit the application form to the Authorised person in the office. To, The Principal, Smt. Kashibai Navale College of Pharmacy, Kondhwa (Bk.), Pune. Sir, I request you to kindly consider my candidature for admission to First Year / Direct Second Year Degree in Pharmacy at your institution. I am submitting herewith all the necessary details and documents. 1. Name in full (Surname)

2. Male / Female


(First Name)

F 3. Date of Birth

4. From Maharashtra State

Yes No

5. If NOT, name the State or Union Territory or State of Domicile 6. Nationality : Indian

Yes No

If NOT Name of the Country (Copy of Proof should be attached) 7. Permanent Address

8. Address for Correspondence 9. Name of the Parent / Guardian

(Father’s Name)

10. Relationship with the Parent / Guardian 11. The name of qualifying or equivalent examination 12. Name of the Board 13. The place of learning in previous two years Year


Name & Address of school (s)

Passed from Maharashtra Yes / No

14 A) Details of Qualifying examination (Std. XII) passed. Month & Year of Passing

Name & Address of institution





Passed from Maharashtra Yes / No


PCB Total

PCM Total

Total Grand

Marks obtained Out of 14 B) Details of passing Diploma in Pharmacy Examination (wherever applicable). Month & Year of Passing

Name & Address of Institution

Passed from Maharashtra Yes / No

14 C) Details of MHT-CET 2009 Examination (If applicable) Bio / Maths Chem. Phy. Total

Total Marks Secured out of 1200

% Marks secured & Class obtained

15. Whether belonging to (Please mark wherever applicable) SC








Marks Obtained Out of 16. 17. 18. 19. 20. 21. 22. 23. 1.





Name of the Caste & Sub caste _________________________________________________________________________________ Whether represented the institution in sports / games Yes / No Name of the events___________________________________________________________________________________________ Whether represented the institution at District Level / National / International Level Yes / No Whether a Non-resident Indian, If yes copy of the proof be attached Yes / No Whether passes the intermediate Drawing Grade Examination Yes / No Whether Hostel Accommodation is required Yes / No DECLARATION BY THE CANDIDATE I hereby solemnly declare that I have read all the Rules of admission to the Degree in Pharmacy. I have consulted my Parent / Guardian and after fully understanding these rules, I have filled in this application 2. I declare that I have not been debarred from studying in any school or college or appearing in any examination during the period of my proposed studies. 3. The information furnished by me in this application is true to the best of my knowledge and belief. 4. I fully understand that no document other than those attached to this application form will be entertained for the purpose of any claim for priority for admission. 5. I hereby agree to conform to the instructions, rules of the University of Pune and those of the institution and also the Act and Laws enforced by the Government. 6. I hereby undertake that I shall pursue the studies and shall not do anything inside or outside the institution, which may result in disciplinary action against me. 7. I understand that the admission being giving to me on my claim on reservation, if any is provisional and the same will be cancelled if the said claim is rejected by any Competent Authority. 8. I fully understand that the Principal of the college will have full liberty to expel / rusticate me from the College for any infringement of the rules of conduct and discipline prescribed by the College / University (if any) and the undertaking given above. 9. Total number of certificates attached with the application form are __________________________ Place :____________________ Date : ____________________ Signature of the candidate _________________

24. DECLARATION BY THE PARENT / GUARDIAN 1. I have studied the rules of admission and agree to the same. 2. The particulars furnished by ward are true to the best of my knowledge. 3. I undertake and bind myself to pay within due date on behalf of my ward such fees, charges and the dues as levied by the authorities from time to time. 4. I will take care of my ward, behave properly and does nothing except in the interest of his studies. Place : ______________________ ______________________________________ Date : ______________________ Signature & Name of the Parent / Guardian CERTIFICATE IN RESPECT OF PHYSICALLY HANDICAPPED CANDIDATES (In Proforma given below) I have throughly examined*Shri / Kum today the day of 20__ and therefore certify that * he / she has following disability :_____________________________________________________________ and that this disability may not make* him / her unfit for and that otherwise *he / she has sound constitution, no disease, no serious defects in eye sight, no physical disability and no mental infirmity. I further certify that * he / she is fit to undergo instructions in Pharmacy and *he / she has nothing that can unfit *him / her now or in future to undergo manual work in laboratories and fields or any outdoor service as a Pharmacist. Fields where *he / she is likely to be unfit are_________________________________________________________________________ Date :________________________________________________________ Signature :______________________________ Address :_____________________________________________________ Name : _________________________________ _____________________________________________________________ Qualification ____________________________ _____________________________________________________________ Registration No. _________________________ SEAL CASTE CERTIFICATE FOR SC / ST (in the following Proforma by the competent authority) This is to certify that *Shri / Ku* son / daughter of _____________________________________________________________________ Shri of * village / town belongs to the *cast / tribe which is recognised as a Scheduled * caste / tribe under the : 1. The Constitution (Scheduled Castes) Order, 1950. 2. The Constitution (Scheduled Tribes) Order, 1950. 3. The Constitution (Scheduled Castes) (Union Territories). 4. The Constitution (Scheduled Tribes) (Union Territories) Order, 1951 as amended by the Scheduled Castes and Scheduled Tribes Lists (Modification) Order 1956. 5. The Bombay Reorganization Act 1960. 6. The Punjab Reorganization Act 1966. 7 The State of Himachal Pradesh Act, 1970. 8. The North Eastern Area (Reorganisation) Act, 1971. 9. The Constition ( Jammu & Kashmir) Scheduled Tribes Order 1956. 10. The Constitution ( Dadra & Nagar Haveli) Scheduled Caste Order 1956. 11. The Constitution ( Dadra & Nagar Haveli). 12. The Constitution (Pondicherry) Scheduled Caste Order 1950. 13. The Constitution (Goa, Daman & Diu) Scheduled Caste Order 1968. 14 The Constitution (Goa, Daman & Diu) Scheduled Tribes Order 1968. 15. The Constitution (Nagaland) Scheduled Tribes Order 1970.

2. *Shri / Smt / Ku. reside(s) in * village / town Place Place ______________________ Date ______________________

and * his / her family ordinarily of * District____________/ Division_____________of *State of Maharashtra Signature _____________________ Designation _____________________

SEAL *Please delete the words which are not applicable. Note : The term ‘ordinarily resides’ used here will have the same meaning as in section 20 of the Representation of Peoples Act, 1950.

CASTE CERTIFICATE FOR DT / NT / OBC / SBC (in the following proforma by the Competent Authority) This is to certify *Shri / Ku _______________________________________________________________________*son / daughter of Shri of * village / town belongs to the *caste tribe which is recognized as a *Denotified Tribe / Nomadic Tribe / Other Backward Class under the Govt. of Maharashtra Social Welfare Department order No Date The said caste / tribe appears at Sr. Number in the said order. 2. * Shri / Smt. / Ku. reside(s) in *village / town Place________________________ Date ________________________

and *his / her family ordinarily of Maharashtra. Signature _____________________ Designation ___________________

of *District

SEAL *Place delete the words which are not applicable. Note : The term *ordinarily resides’ used here will have the same meaning azs in section 20 of the Representation of Peoples Act, 1950.

SCRUTINY FORM (Not to be filled by candidate) (Write Yes, No or N.A. (Not Applicable) wherever applicable under the column remarks for scrutiny) Sr. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Copies of Certificate MHT - CET 2009 Score Card HSC Mark Sheet HSC Passing Certificate Mark sheet of SSC Examination SSC Certificate School / College Leaving Certificate / TC Domicile Certificate in English Caste Certificate of SC/ ST/ OBC/ NT/ DT/ SBC Caste Validity for OBC / NT/ DT/ SBC/ SC/ ST Non Creamy Layer For NT - 2 / NT -3/ OBC Migration Certificate Gap Certificate Character Certificate Medical fitness certificate for physically Handicapped Certificate of NRI

Date : ________________________ Time : ________________________

Remarks for Scrutiny

Signature __________________________________ Name of Scrutinizer __________________________