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Application Form D2D Gujarat

Application Form D2D Gujarat

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Published by: brijpatel909 on Jul 07, 2011
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10/05/2012

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APPLICATION FORM
1.
Name of Board/Uni.
:
2.
MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.:
3.
Month & Year of Passing :
4.
Name of Applicant :(Surname) (Name) (Fathers Name)
5.
Gender : Male Female
6.
Category : Open SC ST SEBC Ex. Serviceman
7.
Discipline from which Diploma passed :
8.
P. H. Y N
9.
H.S.C. Passed : Y N10. Bank Challan No. :
11.
Mobile No. :
ADMISSION COMMITTEE FOR PROFESSIONAL COURSES
L. D. College of Engineering Campus, Ahmedabad-380 015. • Website : www.jacpcldce.ac.in
Merit No.Category
Admission from Diploma in Engineering Courses to Second Year (Third Semester)of Bachelor of Engineering and Technology Courses (2011-12)
AffixPassport SizePhotographRegistration No.:Date:
(For office use only)
Instructions :
1.Read instructions carefully from the website www.jacpcldce.ac.in before filling up theapplication form.2.Use CAPITAL LETTERS only.3.
Candidate who has passed final diploma examination in Nov./Dec. 2010 and April/ May 2011, from TEB / Universities / Institutions situated in Gujarat State areeligible to apply.
4.Form Fee Rs. 350/- is to be paid through bank counter of designeted branches of PNBupto Dt. 17/07/2011 during normal banking hours by producing bank slip (to bedownloaded from website www.jacpcldce.ac.in)5.After filling this form, submit at help centre alongwith bank challan, and xerox copy of allnecessary documents as specified on page No. 3/3 on or before Dt. 17/07/2011 upto5.00 p.m.
072011
MMYYYY
CategoryMerit No.Merit MarksTotal MarksPercentageAdmitted AtSignature ofOfficer
Remarks :
Name and Signature of First Scrutinizer :Name and Signature of Final Scrutinizer :
FOR OFFICE USE ONLY
 
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(Surname) (Name) (Fathers Name)1.Name of Applicant :2.Male / Female : 3. Category :4.Are you physically Handicapped ? Yes No5.Result of Std. Xth (S.S.C.) and XIIth (H.S.C.) Science Stream6.Result of Diploma Courses : Board/Uni.
MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.:
Name of Discipline : Month & Year of Passing :
Sr.No.Courses & SubjectNo./SemesterName of Subject
(Only theory as per mark sheet ofbest of ten / last two semesters
*
)
Theory Marks/ Grade ObtainedOut of
SemesterCourse No.
123456789101112Aggregate % C.P.I. :
 
Theory %
APPLICATION FORM2011-12
Total....
*
As per sub-section 1(c) of section-12 of Admission Rules, if either of the last two semester is having project / trainingexclusively, then enter the theory marks of last two semester excluding the semester having project / training.
Exam.BoardMonth & YearMarks out of 500S.S.C.Exam.BoardMonth & YearMarks of TheoryMarks with PracticalH.S.C.ObtainedOut ofObtainedOut of
 
[ 3 / 4 ]
7.Nationality : 8. Birth Date : 9.Father / Guardians Full Name :Relation with the applicant : Occupation :10.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 myknowledge and belief. I have read the notification No. GH/SH/24/2008/PVS-102008-634-S dtd. 19/07/2008 andit’s amendment. I shall abide by the terms and conditions therein. In the event of suppression or distortion of anyinformation provided in my application form, I understand that admission granted by
The Admission Committeefor Professional Courses, Ahmedabad, Gujarat
is liable for cancellation. I also understand that the decision ofthe
The Admission Committee for Professional Courses
regarding my admission will be final and I shall abideby their decision. Further, if admitted, I promise to abide by the rules and regulations of the Institute as applicableduring the course of study. I am also aware that ragging is banned and if, found guilty, I shall be liable forpunishments as per rules. I abide to pay the fees as decided. I abide to pay the fees as determined by the FeeRegulatory Committee
.
Date: Place:Signature of Father / GuardianSignature 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 passing 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.............................................................................
DDMMYYYYDDMMYYYY

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