Dr. D. Y.
Patil Vidyapeeth
(Deemed University)
Pimpri, Pune – 411 018
EXAMINATION FORM
For Office use only
Exam Fees Rs. :________ Receipt No. :__________ Exam Month & Year :___________
The Controller of Examinations,
Dr. D.Y. Patil Vidyapeeth
Pimpri, Pune – 411 018
Sir,
I request permission to present myself at the ensuing Examination for the
Examination to be held in the month & year
MONTH YEAR
Name of the College :
Student's PRN :
Name of the Student :
As it appears in the
Higher Secondary
Certificate LEAVE ONE SQUARE BLANK AFTER EACH WORD
Address : __________________________________________________________________
PIN Code : ___________ S.T.D. Code :_________ Tel. No.:______________
Male/Female :_________ Category : (General/ Weaker Section/Management Quota): _____
Admission Criteria : (AICET, AIET,MGT, NRI): _______ Date of selection letter : ___________
Date of Admission : __________________ Date of Eligibility : ________________
I will be appearing for the following subjects:
Sr.
Name of the Subject Paper Numbers
No.
1
2
3
4
5
6
7
8
1
DECLARATION
1. I hereby declare that I have not taken any attempt (including the present one) in excess of the maximum
attempts permissible by concerned Statutory Council / Vidyapeeth for the said examination.
2. I hereby declare that I have gone through the syllabus prescribed for the examination for which I am
appearing.
3. I shall be responsible if my application form is rejected for any errors, wrong or incomplete entries made
by me in the examination form.
4. I hereby declare that I shall not claim any concession on religious ground.
5. I am not defying the criteria of the admission order.
6. I am not admitted to the course after the cut-off date declared by the Vidyapeeth for grant of terms.
Yours faithfully,
Date :
Place : Signature of the candidate
CERTIFICATE TO BE SIGNED BY THE HEAD OF THE INSTITUTION
I certify that, Shri/Smt./Kum.:________________________________________________________ is a
bonafide student of this college and has satisfactorily attended the classes and that his/her
1. Attendance is not less than 75% in lecture teaching & in practical work.
2. Eligibility in cases of NRI, Management Quota, AICET,AIET etc. has already been sought
(wherever applicable)
3. I further certify that the candidate is attempting for first time and as per the Vidyapeeth rules
he/she is eligible to appear.
4. The candidate has completed the terms as per Vidyapeeth rules.
5. That he/she is not admitted to the course after the cut-off date for grant of term.
Yours faithfully,
Date : Signature & seal of the Dean/Principal/Director
P.S. Previous year mark sheet must be enclosed for students appearing for the
examination other than First Year of the course.
