0 12. aadhar no. - jceceb.jharkhand.gov.in
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ICR Application Form
Side - A
Polytechnic Entrance Competitive Examination - 2016
Name : ........................................................................................................................................................................................................
Father's Name : .........................................................................................................................................................................................
Address : ...................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................... Dist. ....................................................................
State .......................................................................................................... Pin :
1. Name of the Candidate (as per 10th calss records)
2. Father's Name (as per 10th calss records)2. Father's Name (as per 10th calss records)
1. Name of the Candidate (as per 10th calss records)
3. Date of Birth3. Date of Birth 4. Gender4. Gender 5. Category5. Category (Write the relevant code in the box)(Write the relevant code in the box)
6. MCQ Quota6. MCQ Quota 7. S.M.Q. (Priority Code)(See back side i.e. Side-B)(See back side i.e. Side-B)
Male - MFemale - FMale - MFemale - F
Gen - 1 BC-I - 4SC - 2 BC-II - 5ST - 3ST - 3SC - 2 BC-II - 5Gen - 1 BC-I - 4
Yes - 1No - 2No - 2Yes - 1
YearMonthDate
13. Your Father / Guardian annual Income (Write the relevent code)
Less than Rs. 2,00,001 - 1 In between Rs. 2,00,001 to Rs. 4,50,000 - 2
In between Rs. 4,50,001 to Rs. 10,00,000 - 3 Above Rs. 10,00,001 - 4
14. Application Fee details :- If candidate has submitted by Demand Draft,
1. Demand Draft No. : __________________
2. Demand Draft Amount : ______________
3. Demand Draft Date : _____ / _____ / 2016
In between Rs. 4,50,001 to Rs. 10,00,000 - 3 Above Rs. 10,00,001 - 4
Less than Rs. 2,00,001 - 1 In between Rs. 2,00,001 to Rs. 4,50,000 - 2
If candidate has submitted through CHALLAN
1. Transaction ID: _________________________
3. Deposit Date : _____ / _____ / 2016
2. Application Fee Amount: __________________
(Please ensure that CHALLAN Board's Copy is attached with Application Form)(Please ensure that Demand Draft in ORIGINAL is attached with Application Form)
15. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN
16. Signature of the Candidate
17. Paste Photograph within provided space 18. Left thumb impression
Paste (Do not staple)your Non-attested
Photograph
Date Month Year
--------
Registration No.(Office use only)
1. Transaction ID: _________________________
2. Application Fee Amount: __________________
1. Demand Draft No. : __________________
2. Demand Draft Amount : ______________
(Please ensure that Demand Draft in ORIGINAL is attached with Application Form) (Please ensure that CHALLAN Board's Copy is attached with Application Form)If candidate has submitted by Demand Draft, If candidate has submitted through CHALLAN
Polytechnic Entrance Competitive Examination - 2016
3. Demand Draft Date : _____ / _____ / 2016 3. Deposit Date : _____ / _____ / 2016
9. Exam Centre City Code(See back side i.e. Side-B)(See back side i.e. Side-B)
First ChoiceFirst Choice Second ChoiceSecond Choice
----
10. Correspondence Address
--
PIN Code District Code
(See back side i.e. Side - B for District Code )
District CodePIN Code
011. Mobile No.
12. AADHAR No.(If available)
Pin Code & District Code
8. Handicapped
Phy. Hand.- 3 None - 4
Blindness - 1 Deafness - 2
Phy. Hand.- 3 None - 4
Blindness - 1 Deafness - 2
7. S.M.Q. (Priority Code) 8. Handicapped 9. Exam Centre City Code
11. Mobile No.
12. AADHAR No.
13. Your Father / Guardian annual Income (Write the relevent code)
10. Correspondence AddressPin Code & District Code
YearMonthDateDate Month Year
--------
(If available)
14. Application Fee details :-
15. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN
16. Signature of the Candidate
17. Paste Photograph within provided space 18. Left thumb impression
Note:- Don't enclose any type of Certificates / Documents along with the form, except the requisite DD / Challan.Note:- Don't enclose any type of Certificates / Documents along with the form, except the requisite DD / Challan.
(See back side i.e. Side - B for District Code )
Side - B Polytechnic Entrance Competitive Examination - 20161. Name of the Candidate: _________________________________________________________________
2. Father's Name: ________________________________________________________________________
3. Mother's Name: ________________________________________________________________________
4. Permanent Address: ____________________________________________________________________
________________________________________________________________________________________
Dist. : _________________________________ State: ____________________________________________
Tel. No. / Mobile No.: PIN No. :
5. Visible identification mark of the Candidate: __________________________________________________
6. Date of Birth
YearMonthDateDate Month Year
--------
7. Category (For statistical purpose) [ ]: GEN SC ST BC-I BC-II
8. Gender [ ]: Male Female
9. Declaration of the Candidate:
1. Name of the Candidate: _________________________________________________________________
2. Father's Name: ________________________________________________________________________
3. Mother's Name: ________________________________________________________________________
________________________________________________________________________________________
Dist. : _________________________________ State: ____________________________________________
Tel. No. / Mobile No.:
YearMonthDateDate Month Year
--------
GEN SC ST BC-I BC-II
Male Female
PIN No. :0
I hereby declare that informations furnished above are correct and all certificates in ORIGINAL are lying with me or
I am able to procure required certificates and will be produced at the time of COUNSELLING. I shall forfeit my cand-
idatures as well as liable for legal action in case any of them is proved to be false at any stage of ADMISSION or
thereafter or if I will not produce relevant required ORIGINAL certificates.
11. Candidate's signature
4. Permanent Address: ____________________________________________________________________
5. Visible identification mark of the Candidate: __________________________________________________
6. Date of Birth
7. Category (For statistical purpose) [ ]:
8. Gender [ ]:
9. Declaration of the Candidate:
10. Father's / Guardian's signature10. Father's / Guardian's signature 11. Candidate's signature
Date:- _____ / ______ / 2016
Place:- _________________
Date:- _____ / ______ / 2016
Polytechnic Entrance Competitive Examination - 2016
0707
Bank’s Copy
Challan for Polytechnic Entrance Competitive Examination – 2016 Application
It must be deposited in United Bank of India
A/c No. - 1842010000921 IFS Code - UTBI0SCTQ03
Application Fee:-
Gen/BC – I/BC - II [ ] ` 800/-ST / SC [ ] ` 400/-(Tick [ √ ] which is applicable)
(To be filled up by the Depositor)
Category (mention your category): __________
Father's Name: ________________________
______________________________________
Date of Birth: ___________________________
Mobile No. : ____________________________
Transaction ID: __________________________
NFFT / UTR No. (In case of IFSC):
_________________________
Deposit Date: ____ / ____ / 2016
Signature of Authorized Signatory & Depositor Seal
Board’s Copy
Challan for Polytechnic Entrance Competitive Examination – 2016 Application
It must be deposited in United Bank of India
A/c No. - 1842010000921
Application Fee:-
Transaction ID: __________________________
NFFT / UTR No. (In case of IFSC):
_________________________
Deposit Date: ____ / ____ / 2016
Signature of Authorized Signatory & Depositor Seal
Candidate’s Copy
Challan for Polytechnic Entrance Competitive Examination – 2016 Application
It must be deposited in United Bank of India
A/c No. - 1842010000921
Application Fee:-
Transaction ID: __________________________
NFFT / UTR No. (In case of IFSC):
_________________________
Deposit Date: ____ / ____ / 2016
Signature of Authorized Signatory & Depositor Seal
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Instruction for Candidate:- Submit the requisite Application fee and collect Board's & Candidate's Copy from Bank. Send the Board's Copy with the Application Form.
Gen/BC – I/BC - II [ ] ` 800/-ST / SC [ ] ` 400/-(Tick [ √ ] which is applicable)
Gen/BC – I/BC - II [ ] ` 800/-ST / SC [ ] ` 400/-(Tick [ √ ] which is applicable)
Candidate’s Name: ______________________
______________________________________
(To be filled up by the Depositor)
Category (mention your category): __________
Father's Name: ________________________
______________________________________
Date of Birth: ___________________________
Mobile No. : ____________________________
Candidate’s Name: ______________________
______________________________________
(To be filled up by the Depositor)
Category (mention your category): __________
Father's Name: ________________________
______________________________________
Date of Birth: ___________________________
Mobile No. : ____________________________
Candidate’s Name: ______________________
______________________________________
Instruction for Candidate:- Submit the requisite Application fee and collect Board's & Candidate's Copy from Bank. Send the Board's Copy with the Application Form.
Application Fee:- Application Fee:- Application Fee:-
IFS Code - UTBI0SCTQ03 IFS Code - UTBI0SCTQ03
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