To, Form Number:MUM02208

The Divisional Secretary,

Maharashtra State Board of Secondary And Higher Secondary Education,
MUMBAI Divisional Board.
Sir,
I request you to issue enrolment Certificate as a Private Candidate at the S.S.C Examination(Std.X) to
be held in March 2018 and submit the following particulars for your information.

Full Name HARSH KISHOR KOLOKHE

Mother's Name KAVITA
Residential Address KATURBA ZOPADI SANGH NO. 1,
MAHADEVC NAGAR, ROOM NO. 1/2,
927, KATRAK ROAD, BEHIND WADALA
FISH MARKET, WADALA WEST
Residential PinCode 400031
Residential District MUMBAI
Residential State MAHARASHTRA
Adhar Number 733646134661
Email ID of student yeshcybercafe@gmail.com
Mobile Number 9594484926
Birth Date 11/24/2002
Birth Date In Words November Twenty Fourth Two Thousand
Two
Birth Village/Town MUMBAI
Birth taluka MUMBAI
Birth District MUMBAI
Gender Male
Medium English
Name of Last Attended School SHRI BANSIDHAR AGGARWAL
MODEL SCHOOL AND JR. COLLEGE
village/town of Last Attended School MUMBAI
Taluka of Last Attended School MUMBAI
District of Last Attended School MUMBAI
State of Last Attended School MAHARASHTRA
Pincode Of Last Attended School 400013
Udise Code 27230209222
Is handicap no
Date of leaving the last attended School 30/06/2017
Standard in which studying at the time of 9
leaving school
Pass/Fail/Studying failed
Debarred from appearing at any of the no
examination
 Undertaking to be given by the candidate

i) I,HARSH KISHOR KOLOKHE hereby declare that shall complete the

Practicals,in Science and Technology and Information Communication
Technology Subjects,Self Learning Material Prescribed by the Board and the
Prescribed course of studies for optional/school subject for std.X through the
contact center.If I fail to comply with the same,the decision of the Divisional
Board shall be binding on me.

ii) I am aware that I am not eligible to offer the technical subject.

iii) I am aware that in case any further enquiry (regarding my previous

schooling age,etc.) is found necessary by the authorities concerned and if the
enquiry is not completed in good time, I understand that I shall have to submit
a fresh application for the following examination.

iv) The above information has been filled in by me personally in may own
handwriting and it is as per the original documents produced by me along with
the Application form.I also hereby agree to abide by the Maharshtra Secondary
and Higher Secondary Education Boards Regulation 1977 and all the
instructions issued by the board.

v) I have not passed the SSC Examination,conducted by the Maharashtra State

Board of Secondary & Higher Secondary Education or any other equivalent or
higher examination of any statutory Board or University.

vi)I here by declare that I have not joined any recognised school since I left
the school mentioned at Sr.No.6

Place: MUMBAI Signature Of Applicant

IP: 59.183.38.114
Date: 8/3/2017 9 (HARSH KISHOR KOLOKHE)

Note: Kindly submit application form to

N.K.EDU.SOC.S H.SCHL,SEWRI WADALA ESTATE,MUMBAI 31(-)

Along with original documents and processing fees Rs.1100 before 21st August 2017.
 RECEIPT(For Office Use)

EC NO:MUM02208 Date:8/3/2017 9

From, HARSH KISHOR KOLOKHE Received Rs.ELEVEN HUNDRED

only for the Enrollment & Processing as a private Candidate for SSC
Examination.

Cashier

RECEIPT(For College Use)

EC NO:MUM02208 Date:8/3/2017 9

From, HARSH KISHOR KOLOKHE Received Rs.ELEVEN HUNDRED

only for the Enrollment & Processing as a private Candidate for SSC
Examination.

Cashier

RECEIPT(For Student)

EC NO:MUM02208 Date:8/3/2017 9

From, HARSH KISHOR KOLOKHE Received Rs.ELEVEN HUNDRED

only for the Enrollment & Processing as a private Candidate for SSC
Examination.

Cashier