side - a vocational/i.t.i. to diploma entrance competitive...

ICR Application Form

Side - A

Vocational/I.T.I. to Diploma Entrance Competitive Examination - 2016

Name : ........................................................................................................................................................................................................

Father's Name : .........................................................................................................................................................................................

Address : ...................................................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................... Dist. ....................................................................

State .......................................................................................................... Pin :

1. Name of the Candidate (as per 10th class records)

2. Father's Name (as per 10th class 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. Handicapped

Male - MFemale - FMale - MFemale - F

Gen - 1 BC-I - 4SC - 2 BC-II - 5ST - 3

Blindness - 1 Deafness - 2

ST - 3SC - 2 BC-II - 5Gen - 1 BC-I - 4

Phy. Hand.- 3 None - 4

Blindness - 1 Deafness - 2

Phy. Hand.- 3 None - 4

7. Mobile No.

YearMonthDate

12. 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

13. Application Fee details :- If candidate has submitted by Demand Draft

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 Bank 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)

14. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN

15. Signature of the Candidate

16. Paste Photograph within provided space 17. 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: __________________

(Please ensure that CHALLAN Board's Copy is attached with Application Form)

0

(See back side i.e. Side - B for Group Code)

6. Handicapped

11. Group Code of Vocational Course or I.T.I. Trade10. M.C.Q. Quota(Muslim Community Quota)

Yes - 1No - 2No - 2Yes - 1

2. Father's Name (as per 10th class records)

1. Name of the Candidate (as per 10th class records)

If candidate has submitted through Bank CHALLAN

1. Demand Draft No.: _______________________

3. Deposit Date : _____ / _____ / 2016

2. Demand Draft Amount: ____________________

1. Demand Draft No.: _______________________

2. Demand Draft Amount: ____________________

If candidate has submitted by Demand Draft(Please ensure that Demand Draft in ORIGINAL is attached with Application Form)

8. AADHAR No.(If available)

10. M.C.Q. Quota 11. Group Code of Vocational Course or I.T.I. Trade

12. Your Father / Guardian annual Income (Write the relevent code)

13. Application Fee details :-

14. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN

15. Signature of the Candidate

16. Paste Photograph within provided space 17. Left thumb impression

(See back side i.e. Side - B for District Code)9. Correspondence Address PIN & District Code

--

PIN Code District CodeDistrict CodePIN Code

9. Correspondence Address PIN & District Code


3. Deposit Date : _____ / _____ / 20163. Deposit Date : _____ / _____ / 2016

7. Mobile No.

8. AADHAR No.

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.

Side - B Vocational/I.T.I. to Diploma Entrance Competitive Examination - 2016

(11) Course's/Trade's name and their Group Code

Course's Name

Fitter, Turner, Mechanist, Mech. Motor Vehicle, Machinist Grinder, Mech. Ref. & Air ConditioningDraftsman Mechanical, Instrument Mech. Automobile Engg. & Tech., Production & Manufacturing

Electrical, Wireman, Electroplater, Electrician, Electrical Domestic Appliances

Surveyor, Draftsman Civil

Mech. General Electronics, Mech. Radio & TV, Mech. Consumer Electronics, Mech. Industrial

Group Code

1

1. 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 orI 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 orthereafter 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:- _________________

9

Electonics, Electronics Mechanic, Electronics Technology, Radio TV Technician

I.T. & E.S.M., Mech. Computer Hardware, Computer Science

Mining Geology

23

4

56

(11) Course's/Trade's name and their Group Code

Course's Name

Fitter, Turner, Mechanist, Mech. Motor Vehicle, Machinist Grinder, Mech. Ref. & Air ConditioningDraftsman Mechanical, Instrument Mech. Automobile Engg. & Tech., Production & Manufacturing

Electrical, Wireman, Electroplater, Electrician, Electrical Domestic Appliances

Surveyor, Draftsman Civil

Mech. General Electronics, Mech. Radio & TV, Mech. Consumer Electronics, Mech. Industrial

Group Code

1

Electonics, Electronics Mechanic, Electronics Technology, Radio TV Technician

I.T. & E.S.M., Mech. Computer Hardware, Computer Science

Mining Geology

23

4

56

9


Date:- _____ / ______ / 2016

Bank’s Copy

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


A/c No. - 1842010000921

Application Fee:-

Transaction ID: __________________________


_________________________

Deposit Date: ____ / ____ / 2016


Candidate’s Copy


A/c No. - 1842010000921

Application Fee:-

Transaction ID: __________________________


_________________________

Deposit Date: ____ / ____ / 2016


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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.



Candidate’s Name: ______________________

______________________________________



Father's Name: ________________________

______________________________________

Date of Birth: ___________________________

Mobile No. : ____________________________

Candidate’s Name: ______________________

______________________________________



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

Challan for Vocational / I.T.I. to Diploma Entrance Competitive Examination – 2016 Application Form

