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P.C
C T
Counselling (non-refundable) fee of Rs. 500/- to be paid in the form of Bank Draft to be drawn in favour of Central Selection Committee (E&T)payable at Kolkata and to be deposited in the bank counter opened at the venue of counselling.
Copy of a recent passport size photo of the applicant to be pasted & attested by a responsible person within this box.
JEM Rank in
GEN
YES
BIO (B) PHY (P)
NO
CHEM (C) MATH (M)
NATA SCORE
% (PCB)
ENGLISH
Date of Birth DD MM YY
Full Marks
Marks Obtained
Name of the Applicant (IN BLOCK LETTER) First Name Middle Name (If Any) Surname
Fathers /Mothers/ *Guardians Name
Mailing address
Pin Code
I declare that the statement given above are true to the best of my knowledge Counter Signature of Parent / Guardian in full Signature of the candidate in full
DECLARATION
BE / B Tech./ B Phram
BE / B Tech./B. Pharm/
Only B. Pharm
SPACE FOR OFFICIAL STAMP The following allotment code is the option exercised by me based on the availability of seats at the instant of my counselling. I will not claim any other seat in future. I understand that if I do not take admission to the allotted college / Institution within stipulated time, my allotment shall stand cancelled. ALLOTMENT CODE ....................................... Signature of the Candidate in Full
Please bring one copy of this counselling form duly filled in and signed before appearing in the counselling PLEASE ALSO DOWNLOAD IMPORTANT INFORMATION PERTAINING TO COUNSELLING