s

E C
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JEM Enrolment No.

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.

CENTRAL SELECTION COMMITTEE (ENGG & TECH)

COUNSELLING FORM (Engg & Tech) for JEM 2010 ( 1st Phase )
AIEEE Enrolment No.
Attested copy of a
recent passport
size photo of
the applicant to be
pasted
within this box.
AIEEE RANK (if any)
JEM Rank in All India Rank Whether cleared NATA (Please Tick)
(OVERALL)
GEN YES NO
Whether domiciled in West Bengal (Please Tick)
ENGG. S.C YES NO NATA SCORE
&
TECH. S.T
Marks obtained in H.S (10+2) or equivalent exam.
BIO PHY CHEM MATH % % VERNACULAR
P.C (B) (P) (C) (M) (PCM) (PCB) ENGLISH /5th SUBJECT

Full Marks
Date of Birth
Marks
DD MM YY Obtained

Name of the Applicant (IN BLOCK LETTER)

First Name

Middle Name
(If Any)
Surname

Fathers /Mothers
*Guardians Name
(* if father and mother are not alive)

Mailing
address

Pin Code Tele Phone Number

DECLARATION
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

(For office use only)

Eligible for admission to
( To be ticked by the verifying officer )

BE / B Tech./ B Phram BE / B Tech./B. Pharm/ Only B. Pharm C E

B.Arch
A
FO P
SPACE FOR OFFICIALA
ST
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
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