Application Form D2d Gujarat 4p1u2b
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ISSION COMMITTEE FOR PROFESSIONAL COURSES L. D. College of Engineering Campus, Ahmedabad-380 015. • Website : www.jacldce.ac.in
APPLICATION FORM
ission from Diploma in Engineering Courses to Second Year (Third Semester) of Bachelor of Engineering and Technology Courses (2011-12) Registration No. : Date
:
—
—
— 0
—
7 — 2
—
0
1
Merit No.
1
Category
(For office use only) Instructions : 1. Read instructions carefully from the website www.jacldce.ac.in before filling up the application form. 2. Use CAPITAL LETTERS only. 3. Candidate who has ed final diploma examination in Nov./Dec. 2010 and April/ May 2011, from TEB / Universities / Institutions situated in Gujarat State are eligible to apply. 4. Form Fee Rs. 350/- is to be paid through bank counter of designeted branches of PNB upto Dt. 17/07/2011 during normal banking hours by producing bank slip (to be ed from website www.jacldce.ac.in) 5. After filling this form, submit at help centre alongwith bank challan, and xerox copy of all necessary documents as specified on page No. 3/3 on or before Dt. 17/07/2011 upto 5.00 p.m.
Affix port Size Photograph
1. Name of Board/Uni. : 2. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: 3. Month & Year of ing : M M — Y
Y
Y
Y
4. Name of Applicant : (Surname) 5. Gender :
Male
(Name)
Female 6. Category :
Open
(Father’s Name)
SC
ST
Y
N
7. Discipline from which Diploma ed : 8. P. H.
Y
10. Bank Challan No. : Remarks :
9. H.S.C. ed :
N –
11. Mobile No. :
FOR OFFICE USE ONLY Category Merit No. Merit Marks
Name and Signature of First Scrutinizer :
Total Marks Percentage itted At
Name and Signature of Final Scrutinizer :
Signature of Officer [1/4]
SEBC
Ex. Serviceman
APPLICATION FORM 2011-12 (Surname)
(Name)
(Father’s Name)
1. Name of Applicant : 2. Male / Female
:
3. Category :
4. Are you physically Handicapped ? Yes
No
5. Result of Std. Xth (S.S.C.) and XIIth (H.S.C.) Science Stream Exam.
Board
Month & Year
Marks out of 500
Board
Month & Year
Marks of Theory
S.S.C. Exam. H.S.C.
Obtained
Marks with Practical
Out of
Obtained
Out of
6. Result of Diploma Courses : Board/Uni. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: Name of Discipline : Sr. No.
Month & Year of ing :
Courses & Subject No./Semester Semester
Name of Subject
(Only theory as per mark sheet of best of ten / last two semesters*)
Course No.
Theory Marks/ Grade Obtained
Out of
1 2 3 4 5 6 7 8 9 10 11 12 Total.... Aggregate %
C.P.I. :
N
Theory %
* As per sub-section 1(c) of section-12 of ission Rules, if either of the last two semester is having project / training
exclusively, then enter the theory marks of last two semester excluding the semester having project / training. [2/4]
8. Birth Date : D
7.
Nationality :
9.
Father / Guardian’s Full Name : Relation with the applicant
10.
:
D —M M — Y Y
Y Y
Occupation :
Write address for Correspondence : (Do not write your name) Address : Address : Address : City
:
Pincode :
Phone : (With STD Code ) Mobile No. :
DECLARATION BY THE CANDIDATE I hereby declare that all the particulars stated in the application are true and correct to the best of my knowledge and belief. I have read the notification No. GH/SH/24/2008/PVS-102008-634-S dtd. 19/07/2008 and it’s amendment. I shall abide by the and conditions therein. In the event of suppression or distortion of any information provided in my application form, I understand that ission granted by The ission Committee for Professional Courses, Ahmedabad, Gujarat is liable for cancellation. I also understand that the decision of the The ission Committee for Professional Courses regarding my ission will be final and I shall abide by their decision. Further, if itted, I promise to abide by the rules and regulations of the Institute as applicable during the course of study. I am also aware that ragging is banned and if, found guilty, I shall be liable for punishments as per rules. I abide to pay the fees as decided. I abide to pay the fees as determined by the Fee Regulatory Committee.
Date : D
D — M M — Y Y
Y Y
Place :
Signature of Father / Guardian
Signature of Applicant
Enclosures : Please tick mark in the box where copies are attached : 1.
Xth (S.S.C.) Mark Sheet ....................................................................................................................................
2.
XIIth (H.S.C.) Mark Sheet ..................................................................................................................................
3.
Best of Ten / Last two Semester Mark Sheet / C.P.I. Certificate (whatever is applicable) ...............................
4.
Diploma ing certificate from TEB / Head of Institute / University ..............................................................
5.
School Leaving Certificate ................................................................................................................................
6.
Caste Certificate from competent authority (for SC/ST/SEBC category) .........................................................
7.
Non creamylayer certificate issued after 1st April, 2010 (For SEBC category only) ........................................
8.
PH Certificate from the competent authority .....................................................................................................
9.
Ex/In Serviceman Certificate from the competent authority ............................................................................. [3/4]
Commissionerate of Technical Education, Gujarat State ission Committee For Professional Courses (AC) Bank Challan of Application Fee for ission in Diploma to Degree Engineering To be filled by Candidate Name
AC Copy
To be filled by Bank PNB Bank A/c. No. : 6700000100002691
:
Amount of Fee Rs. 350/- in cash only. Board
:
Bank Seal :
MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.
:
Date
:
Bank Transaction No. :
–
Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cut From Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Commissionerate of Technical Education, Gujarat State ission Committee For Professional Courses (AC) Bank Challan of Application Fee for ission in Diploma to Degree Engineering To be filled by Candidate Name
:
Board
:
Candidate Copy
To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only. Bank Seal :
MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.
:
Date
:
Bank Transaction No. :
–
Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cut From Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Commissionerate of Technical Education, Gujarat State ission Committee For Professional Courses (AC) Bank Challan of Application Fee for ission in Diploma to Degree Engineering To be filled by Candidate Name
:
Board
:
Bank Copy
To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only.
MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.
Bank Seal : :
Date
:
Bank Transaction No. :
–
Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.
[4/4]
APPLICATION FORM
ission from Diploma in Engineering Courses to Second Year (Third Semester) of Bachelor of Engineering and Technology Courses (2011-12) Registration No. : Date
:
—
—
— 0
—
7 — 2
—
0
1
Merit No.
1
Category
(For office use only) Instructions : 1. Read instructions carefully from the website www.jacldce.ac.in before filling up the application form. 2. Use CAPITAL LETTERS only. 3. Candidate who has ed final diploma examination in Nov./Dec. 2010 and April/ May 2011, from TEB / Universities / Institutions situated in Gujarat State are eligible to apply. 4. Form Fee Rs. 350/- is to be paid through bank counter of designeted branches of PNB upto Dt. 17/07/2011 during normal banking hours by producing bank slip (to be ed from website www.jacldce.ac.in) 5. After filling this form, submit at help centre alongwith bank challan, and xerox copy of all necessary documents as specified on page No. 3/3 on or before Dt. 17/07/2011 upto 5.00 p.m.
Affix port Size Photograph
1. Name of Board/Uni. : 2. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: 3. Month & Year of ing : M M — Y
Y
Y
Y
4. Name of Applicant : (Surname) 5. Gender :
Male
(Name)
Female 6. Category :
Open
(Father’s Name)
SC
ST
Y
N
7. Discipline from which Diploma ed : 8. P. H.
Y
10. Bank Challan No. : Remarks :
9. H.S.C. ed :
N –
11. Mobile No. :
FOR OFFICE USE ONLY Category Merit No. Merit Marks
Name and Signature of First Scrutinizer :
Total Marks Percentage itted At
Name and Signature of Final Scrutinizer :
Signature of Officer [1/4]
SEBC
Ex. Serviceman
APPLICATION FORM 2011-12 (Surname)
(Name)
(Father’s Name)
1. Name of Applicant : 2. Male / Female
:
3. Category :
4. Are you physically Handicapped ? Yes
No
5. Result of Std. Xth (S.S.C.) and XIIth (H.S.C.) Science Stream Exam.
Board
Month & Year
Marks out of 500
Board
Month & Year
Marks of Theory
S.S.C. Exam. H.S.C.
Obtained
Marks with Practical
Out of
Obtained
Out of
6. Result of Diploma Courses : Board/Uni. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: Name of Discipline : Sr. No.
Month & Year of ing :
Courses & Subject No./Semester Semester
Name of Subject
(Only theory as per mark sheet of best of ten / last two semesters*)
Course No.
Theory Marks/ Grade Obtained
Out of
1 2 3 4 5 6 7 8 9 10 11 12 Total.... Aggregate %
C.P.I. :
N
Theory %
* As per sub-section 1(c) of section-12 of ission Rules, if either of the last two semester is having project / training
exclusively, then enter the theory marks of last two semester excluding the semester having project / training. [2/4]
8. Birth Date : D
7.
Nationality :
9.
Father / Guardian’s Full Name : Relation with the applicant
10.
:
D —M M — Y Y
Y Y
Occupation :
Write address for Correspondence : (Do not write your name) Address : Address : Address : City
:
Pincode :
Phone : (With STD Code ) Mobile No. :
DECLARATION BY THE CANDIDATE I hereby declare that all the particulars stated in the application are true and correct to the best of my knowledge and belief. I have read the notification No. GH/SH/24/2008/PVS-102008-634-S dtd. 19/07/2008 and it’s amendment. I shall abide by the and conditions therein. In the event of suppression or distortion of any information provided in my application form, I understand that ission granted by The ission Committee for Professional Courses, Ahmedabad, Gujarat is liable for cancellation. I also understand that the decision of the The ission Committee for Professional Courses regarding my ission will be final and I shall abide by their decision. Further, if itted, I promise to abide by the rules and regulations of the Institute as applicable during the course of study. I am also aware that ragging is banned and if, found guilty, I shall be liable for punishments as per rules. I abide to pay the fees as decided. I abide to pay the fees as determined by the Fee Regulatory Committee.
Date : D
D — M M — Y Y
Y Y
Place :
Signature of Father / Guardian
Signature of Applicant
Enclosures : Please tick mark in the box where copies are attached : 1.
Xth (S.S.C.) Mark Sheet ....................................................................................................................................
2.
XIIth (H.S.C.) Mark Sheet ..................................................................................................................................
3.
Best of Ten / Last two Semester Mark Sheet / C.P.I. Certificate (whatever is applicable) ...............................
4.
Diploma ing certificate from TEB / Head of Institute / University ..............................................................
5.
School Leaving Certificate ................................................................................................................................
6.
Caste Certificate from competent authority (for SC/ST/SEBC category) .........................................................
7.
Non creamylayer certificate issued after 1st April, 2010 (For SEBC category only) ........................................
8.
PH Certificate from the competent authority .....................................................................................................
9.
Ex/In Serviceman Certificate from the competent authority ............................................................................. [3/4]
Commissionerate of Technical Education, Gujarat State ission Committee For Professional Courses (AC) Bank Challan of Application Fee for ission in Diploma to Degree Engineering To be filled by Candidate Name
AC Copy
To be filled by Bank PNB Bank A/c. No. : 6700000100002691
:
Amount of Fee Rs. 350/- in cash only. Board
:
Bank Seal :
MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.
:
Date
:
Bank Transaction No. :
–
Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cut From Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Commissionerate of Technical Education, Gujarat State ission Committee For Professional Courses (AC) Bank Challan of Application Fee for ission in Diploma to Degree Engineering To be filled by Candidate Name
:
Board
:
Candidate Copy
To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only. Bank Seal :
MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.
:
Date
:
Bank Transaction No. :
–
Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cut From Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Commissionerate of Technical Education, Gujarat State ission Committee For Professional Courses (AC) Bank Challan of Application Fee for ission in Diploma to Degree Engineering To be filled by Candidate Name
:
Board
:
Bank Copy
To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only.
MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.
Bank Seal : :
Date
:
Bank Transaction No. :
–
Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.
[4/4]
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