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7/22/2017 STUDENT COPY Smt. Surajben Gordhanbhai Patel Commerce and Arts College for Girls (33815) Application No : 71674 Near S. R. Patel Petrol Pump, Nizampura Road,Vadodara PRN : 2016033800001251 The Maharaja Sayajirao University of Baroda Fatehgunj, Vadodara-390 002, Gujarat (India) Academic Year: 2017-2018Course Applied for : B.Com.(with Credits) - Regular - FoC [BCOM] CBCS 2012 - BCom-II FSBCOM-II (FCBCOM)Application Date : 22/07/2017 Payment Category : 5Exam Center Name [Code] : - [-]1.Personal InformationCandidate's Name(Regional) :Candidate's Name as printed on School LIPSA JENAleaving/Passing Certificate : [*This name will appear on all University records/documents]Father's/Husband's Name : RAMESH CHANDRA Mother's Name : SANJUKTA JENA JENA JENAMarital Status : UnMarried Mother Tongue :Place Of Birth : ORISSA Gender : Female Date Of Birth (DD/MM/YYYY) : 18/05/1998Blood Group : Religion : Country of Citizenship :Is Student NRI/ Foreign National : NoAddress For Correspondence :State : Gujarat District : Vadodara Tehsil : Vadodara City/Town/Village :Address (House C/O SGT RC JENA QTR NO 265/02 AIR FORCE STATION DARJIPURA Pin Code : 390022no,street/area/suburb etc.) :Contact detailsMobile Number 918238800782 Email ID: [email protected] Reservation InformationCategory Type : Open Category : GENIs Specially Abled?No3.Social Information(Additional Inforamtion)Paper Selected for: ACF1301 - Elements of Direct Taxes CBM1302 - Human Resource ManagementMedium of Instruction : English CBM1304 - Human Resource Development, Welfare and Social Security FSBCOM-II CBM1301 - Principles of Management ACF1302 - Cost Accounting BEC1301 - Macro Economic Theory CBM1305 - Business Ethics SSBCOM-IIBEC1401 - Macro Economic Issues and Policies ACF1401 - Elements of Indirect TaxesACF1402 - Management Accounting CBM1402 - Entrepreneurship & Small Business ManagementCBM1401 - Marketing Management CBM1404 - Theory & Practice of Industrial RelationsCBM1406 - Managerial Decision TheoryAdmission Fee Payment Details Transaction Date : 22/07/2017Fee Category : Admission Fees - Regular - Girls - Transaction Type : Online Payment Transaction Number :[MSURP] 716741500713413070Admission Fees - 500 Miscellaneous Fees - 200Fine/Late Fees - 0 Foreign Students Co-ordination Fees - 0Additional Hostel Fees - 0 Tuition fees - 0Faculty/College Development and Maintenance Fund - 700 University Development and Maintenance Fund - 1000Library & Learning Resources Fund - 200 Internal Assessment Fees - 100Facilities & Services Charges - 1600 Academic Activity Fees - 100MSU Union Membership Fees - 25 Faculty/College Students Association Fees - 25Sports & Physical Education Activities Fees - 50 Economically Disadvantaged Students' Support Fund - 200Examination Fees - 1180 Total : 5880 1/2

7/22/20174.Guardian InformationOccupation of Guardian : Annual Income of Guardian ( ₹ ) :5.Educational Details Name of Name of Board/University and Name of Month and Year Exam Certificate Mark Out CGPAExamination State of University School/College of Passing Seat No. No. Obtained OfStd 12th 12th May 2016 -- -- 301.00 500.00 -- - --(Commerce)Your Last Qualifying Exam:7.Other InformationWould you like to apply for Hostel accommodation required NADECLARATIONI 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 dounderstand that I need to obtain and produce all the required documents. I LIPSA JENA, Application No : 71674 admit to having understood whatconstitutes ragging and sexual harassment. I have read the guidelines related to the same. I hereby affirm that if found guilty of ragging or sexualharassment I am liable for punishment according to the university regulations.I will undergo Thalassemia Test before the First Semester Examination. I hereby declare that I shall refrain from engaging in any behavior or activity thatis 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 theself-attested copies of all required documents, as mentioned in the respective prospectus and identical photograph pasted at the appropriate place.On onecopy 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 asper the requirement of the program and faculty norms. See Faculty Prospectus for Details.Place : Date : ( Signature of the Candidate ) Signature and DateFor College/Institute/Study Center Use OnlyDesignation Remarks / Particulars / RecommendationsAdmission ClerkAdmissionCommitteeAccountant/Cashier Cash Received: Rs. Receipt No.: Date:Registrar/OfficeSuperintendent 2/2