7/26/2019

STUDENT COPY

Faculty of Technology & Engineering (3386) Application No :

Vadodara
The Maharaja Sayajirao University of Baroda 101939
Fatehgunj, Vadodara-390 002, Gujarat (India) Regular
Academic Year: 2019-2020

Course Applied for : Master of Engineering-Chemical (Polymer Technology)-Regular-ME-II-ME Part-III & IV (-) PRN:2017033800118487
Application Date : 26/07/2019 Payment Category : 2
Exam Center Name [Code] : - [-]
1.Personal Information
Candidate's Name(Regional) :
Candidate's Name as printed on School DARJI VIVEK SANJAYBHAI
leaving/Passing Certificate : [*This name will appear on all University records/documents]
Father's/Husband's Name : SANJAYBHAI DARJI Mother's Name : SURYABEN
Marital Status : UnMarried Mother Tongue :
Place of Birth : SANODA Gender : Male Date of Birth (DD/MM/YYYY) : 03/09/1996
Blood Group : Religion : Country of Citizenship : India
Height : Not Available Weight : Not Available Hemoglobin : Not Available
Is Student NRI/ Foreign National : No Domicile State:
Address For Correspondence :
Location Area : Not
State : Gujarat District : Gandhinagar Tehsil/Taluka : Dehgam City/Town/Village :
Available
Address (House
16 HARI OM SOCIETY STATION ROAD DAHGAM Pin Code : 382305
no,street/area/suburb etc.) :
Contact details
Mobile Number 919737703646 Email ID: vivekdarji85@yahoo.in
2.Legal Reservation Information
Category Type : Reserved Category : SEBC
Is Specially Abled? No Are you Employed/Self-employed? NO
3.Social Information(Additional Information)

Paper Selected for:

ME Part-III & IV
CHL2402 - Research Project

Medium of Instruction : English

Admission Fee Payment Details Payment Status : Paid Transaction Date : 26/07/2019
Fee Category : Admission Fees - Regular - Boys - Transaction Number :
Transaction Type : Online Payment
[MSURP] 1019391564144068555
Admission Fees - 500 Laboratory/Field Work/Studio Fees - 1000
Equipment Maintenance Fees - 300 Miscellaneous Fees - 200
Fine/Late Fees - 0 Tuition fees [Adjustment] - 0
Tuition fees - 1500 Faculty/College Development and Maintenance Fund - 850
University Development and Maintenance Fund - 1200 Library & Learning Resources Fund - 200
Internal Assessment Fees - 100 Facilities & Services Charges - 1750
Academic Activity Fees - 100 MSU Union Membership Fees - 25
Faculty/College Students Association Fees - 25 Sports & Physical Education Activities Fees - 50
Economically Disadvantaged Students' Support Fund - 200 Examination Fees - 1300
Total : 9300
4.Guardian Information
Occupation of Guardian : Business Annual Income of Guardian : 40000
5.Educational Details

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Month and Exam

Name of Name of Board/University and State of Name of Certificate Mark Out
Year of Seat CGPA %
Examination University School/College No. Obtained Of
Passing No.
GUJARAT SECONDARY AND HIGHER
Std 10th SECONDARY EDUCATION BOARD, March 2011 -- -- 377.00 500.00 -- - -- 75.40
GANDHINAGAR,
GUJARAT SECONDARY AND HIGHER
Std 12th 12th
SECONDARY EDUCATION BOARD, March 2013 -- -- 390.00 650.00 -- - -- 60.00
(Science)
GANDHINAGAR,
Your Last Qualifying Exam:
7.Other Information
Would you like to apply for Hostel accommodation required NA
DECLARATION
I hereby declare that all the information furnished by me in this application form is true, complete and correct to the best of my knowledge and belief. I do
understand that I need to obtain and produce all the required documents.
I admit to having understood what constitutes ragging and sexual harassment. I have read the guidelines related to the same. I hereby affirm that if found
guilty of ragging or sexual harassment I am liable for punishment according to the university regulations. "I hereby confirm that I will SUBMIT SYSTEM
GENERATED APPLICATION-FORM along with necessary enclosures required to verify the Academic credentials and Personal details (Like Mark-
sheets, Degree Certificates, Caste Certificates-if applicable…etc.) to the concerned Faculty/College under which I have applied through this application,
at the time of "Merit-based Admission Schedule/Spot Admission Schedule" as available under the Prospectus/Published on the University website as
notified by the concerned Dean of the Faculty/Principal of the College."
I will undergo Thalassemia Test before the First Semester Examination. I hereby declare that I shall refrain from engaging in any behavior or activity that
is prohibited as per the university regulations.
Note: Candidate must carry two copies of above printout of his/her “Application Form” at the time of entrance test/merit based admissions, along with the
self-attested copies of all required documents, as mentioned in the respective prospectus and identical photograph pasted at the appropriate place.On one
copy of the application form , Candidate signs partially on the photograph and partially out side at the time of handing over the form.
Completing the online application form does not guarantee admission in that particular course/program. All admissions are through entrance test/merit as
per the requirement of the program and faculty norms. See Faculty Prospectus for Details.

Place : Date :
( Signature of the Candidate )
Document printed on

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