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LADY BRABOURNE COLLEGE


P-1/2, Suhrawardy Avenue Kolkata - 700 017

Application for Admission to B.Sc.


Subject Microbiology FOR OFFICE USE ONLY Checked & Verified Sd/For Department
Date:- 04 June 2012 Application No.: 2468 1. Name in full MANISHA DAS 3. Sex Female 6. Religion HINDUISM 4. Marital Status Unmarried 7. Physically Handicapped No

SC N

ST N

H N

Approved Sd/Sign. of the Principal

2. Date of Birth 12/6/1994 5. Nationality INDIAN 8. Category General 9. Year of passing H.S/Equivalent

2012

10. Subject combination for Honours course: I) Elective Subjects II) Language group English (compulsory) and Bengali III) Self Financing Course Computer Application - Yes Spanish - No

Chemistry & Physics,

11. (a) Father's / Guardian's Name TARUN DAS (b) Father's Occupation SERVICE (c) Mother's Name SWAPNA DAS (d) Annual Family Income (In Rs.) 350000

12. Guardian's Name and Relationship TARUN DAS --- FATHER 13. Permanent Address 1/5, ALAUDDIN KHAN BITHI , CITY CENTRE , DURGAPUR

(a) Name of City / Village DURGAPUR (b) District BURDWAN (c) Pin 713216 (d) Contact No. STD 0343 No. 2547341 14. Local Guardian's Name and Address MANIK PODAR ( WIRELESS OPERATOR ) 3, MANIK BANDOPADHYAY SARANI KOLKATA-700040 (a) Contact No. STD 033 No. 09051610236

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15. Father's/Guardian's Office Address CONTAI POLICE TELECOMMUNICATION STATION CONTAI, DISTPURBA MEDINIPUR (a) Contact No. STD 03220 No. 255094 16. Result declared by your Board Passed 17. Blood Group B+ RESULT OF QUALIFYING EXAMINATION Name MANISHA DAS Roll No. 6610310 Year 2012 Index No./Registration No. Year: 2010 Institution Name DAV MODEL SCHOOL DURGAPUR

Institution Address J . M . SENGUPTA ROAD , B-ZONE , DURGAPUR


Sr. 1. 2. 3. 4. 5. 6. 7. Subject ENGLISH BENGALI PHYSICS CHEMISTRY BIOLOGY MATHEMATICS Environmental Science Full Marks Theory Practical 100 0 0 0 100 0 100 0 100 0 100 0 0 Pass Marks Marks Obtained Theory Practical Theory Practical 33 0 91 0 0 0 33 0 75 33 0 87 33 0 95 33 0 80 0 Aggregate% (Best Four Subjects)

88.25%

I hereby declare that all the information given above are true to the best of my knowledge. I agree to abide by all the rules of the College / College Hostel which are stated in the College Prospectus. DOCUMENTS TO BE PRODUCED AT THE TIME OF ADMISSION (i) Original & Attested copy of marksheet of the last examination and Admit card of secondary or equivalent examination (to be attested by the Head of Institution last attended). (ii) Original & Attested copy of marksheet of the secondary examination only for "GEOGRAPHY HONOURS" candidates (to be attested by the Head of Institution last attended). (iii) Attested copy of SC, ST certificate (For SC/ST candidates only). The original certificate must be produced at the time of admission. (iv) Two Passport size photographs, attested by the head of the institution last attended. (v) Acknowledgement of the application form. Candidates appearing for Admission Test/Interview must carry :(i) Original Admit Card of the last examination appeared. (ii) Original Marksheet of the last examination appeared. (iii) Applicants copy of the Challan. (iv) One passport size photograph of the candidate. Instructions to Candidates :(i) Candidate must pay the Application Fee of Rs. 100/- along with the Challans generated after successful online submission of the form at Indian Bank from 01/06/2012 to 14/06/2012, otherwise the form will be rejected. (ii) Retain the Applicant's Copy of the Challan for future production. (iii) Candidate must retain the Application Form generated after successful online submission of the form and produce the same at the time of admission.

Date

Signature of Parent / Guardian

Signature of Applicant

Sr. No. 1

Application History Submitted on 04/06/2012 20:25:51

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INDIAN BANK
DATE: 04 June 2012 LADY BRABOURNE COLLEGE A/c. No.6035277389 INDIAN BANK BRANCH:APPLICANT'S COPY

Application No. : L02468 Name :MANISHA DAS

Bank Ref. No. : MU00522451

Honours : Microbiology

AMOUNT : Rs. 100/- [Rs. 80/- Application Fees + Rs. 20/- Bank Charges]
Received Rs. 100/- as application fees for admission to the 1st year B.A./ B.Sc. Class at Lady Brabourne College, Kolkata

Signature with seal of Receiving Authority

INDIAN BANK
DATE: 04 June 2012 LADY BRABOURNE COLLEGE A/c. No.6035277389 INDIAN BANK BRANCH:COLLEGE'S COPY

Application No. : L02468 Name :MANISHA DAS

Bank Ref. No. : MU00522451

Honours : Microbiology

AMOUNT : Rs. 100/- [Rs. 80/- Application Fees + Rs. 20/- Bank Charges]
Received Rs. 100/- as application fees for admission to the 1st year B.A./ B.Sc. Class at Lady Brabourne College, Kolkata

Signature with seal of Receiving Authority

INDIAN BANK
DATE: 04 June 2012 LADY BRABOURNE COLLEGE A/c. No.6035277389 INDIAN BANK BRANCH:BANK'S COPY

Application No. : L02468 Name : MANISHA DAS

Bank Ref. No. : MU00522451

Honours : Microbiology

AMOUNT : Rs. 100/- [Rs. 80/- Application Fees + Rs. 20/- Bank Charges]
Received Rs. 100/- as application fees for admission to the 1st year B.A./ B.Sc. Class at Lady Brabourne

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College, Kolkata
Print

Signature with seal of Receiving Authority

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