You are on page 1of 3

Side - A

SECTION - A

B.Sc. Nursing Entrance Competitive Examination - 2015

Application Form

Registration No.
(Office use only)

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

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

3. Husband Name (if Married)

4. Date of Birth
Date

Month

--

5. Gender
Male - M
Female - F

Year

--

7. Handicapped
Blindness - 1 Deafness - 2
Phy. Hand.- 3 None
- 4

8. Mobile No.

6. Category (Write the relevant code in the box)
Gen - 1
BC-I - 4
SC - 2
BC-II - 5
ST - 3

0

9. AADHAR No.
(If available)

10. Subject Group Code applying for

11. Correspondence Address PIN & District Code
B.Sc. Nursing (Basic Course)
- 1
B.Sc. Nursing (Post Basic Course) - 2

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

-PIN Code

12. Application Fee details :If candidate has submitted by Demand Draft,
(Please ensure that Demand Draft in ORIGINAL is attached with Application Form)

District Code

If candidate has submitted through CHALLAN
(Please ensure that CHALLAN Board's Copy is attached with Application Form)

1. Demand Draft No. : __________________
2. Demand Draft Amount : ______________

1. Transaction ID: _________________________
2. Application Fee Amount: __________________

3. Demand Draft Date : _____ / _____ / 2015

3. Deposit Date : _____ / _____ / 2015

SECTION - B

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

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

Paste (Do not staple)
your Non-attested
Photograph

...................................................................................................................................... Dist. ....................................................................
State ..........................................................................................................

Pin :

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

14. Signature of the Candidate

: 6. Date:. Father's / Guardian's / Husband's signature 11 12. Husband's Name (if Married): ______________________________________________________________ 5. No. Category (For statistical purpose) [ 9. Name of the Candidate: _________________________________________________________________ 2._____ / ______ / 2015 Place:. Candidate's signature .B B.Sc._________________ 11. Permanent Address: ____________________________________________________________________ ________________________________________________________________________________________ Dist. Mother's Name: ________________________________________________________________________ 4.2015 1. Nursing Entrance Competitive Examination . Declaration of the Candidate: I hereby declare that informations furnished above are correct and all certificates in ORIGINAL are lying with me or I am able to procure required certificates and will be produced at the time of COUNSELLING. : _________________________________ State: ____________________________________________ Tel. Father's Name: ________________________________________________________________________ 3.: 0 PIN No. Gender [ ]: Male Year ]: GEN SC ST BC-I BC-II Female 10. I shall forfeit my candidatures as well as liable for legal action in case any of them is proved to be false at any stage of ADMISSION or thereafter or if I will not produce relevant required ORIGINAL certificates. Visible identification mark of the Candidate: __________________________________________________ Date 7. / Mobile No. Date of Birth Month -- -- 8.Side .

Send the Board's Copy with the Application Form.Jharkhand Combined Entrance Competitive Examination Jharkhand Combined Entrance Competitive Examination Jharkhand Combined Entrance Competitive Examination Board’s Copy Candidate’s Copy Challan for B.F 1842010000921 UTBI0SCTQ03 Application Form Fee*:Gen/BC – I/BC .F 1842010000921 UTBI0SCTQ03 Application Form Fee*:Gen/BC – I/BC .II [ ] ST / SC [ ] (Tick [ √ ] which is applicable) ` 550/` 275/- * .JCECEBoard A/c . IFSC No. Bank’s Copy Account Name A/c No.II [ ] ST / SC [ ] (Tick [ √ ] which is applicable) ` 550/` 275/- * .08.Last date for submitting the Fee is 24.. (In case of IFSC): NFFT / UTR No.Sc.Sc. (In case of IFSC): _________________________ _________________________ _________________________ Deposit Date: ____ / ____ / 2015 Deposit Date: ____ / ____ / 2015 Deposit Date: ____ / ____ / 2015 Signature of Depositor Signature of Depositor Signature of Depositor Authorized Signatory & Seal Authorized Signatory & Seal Authorized Signatory & Seal Instruction for Candidate:.E.Last date for submitting the Fee is 24.E.2015.JCECEBoard A/c .Last date for submitting the Fee is 24.2015.. (To be filled up by the Depositor) Candidate’s Name: ______________________ Candidate’s Name: ______________________ Candidate’s Name: ______________________ ______________________________________ ______________________________________ ______________________________________ Category (mention your category): __________ Category (mention your category): __________ Category (mention your category): __________ Father’s Name: _________________________ Father’s Name: _________________________ Father’s Name: _________________________ ______________________________________ ______________________________________ ______________________________________ Date of Birth: ___________________________ Date of Birth: ___________________________ Date of Birth: ___________________________ Mobile No. - C. Nursing Entrance Competitive Examination – 2015 Application Form Cash can be deposited at any Branch of United Bank of India Cash can be deposited at any Branch of United Bank of India Cash can be deposited at any Branch of United Bank of India Account Name A/c No.E. Nursing Entrance Competitive Examination – 2015 Application Form Challan for B. (In case of IFSC): NFFT / UTR No. : ____________________________ Mobile No.Submit the requisite Application Form fee and collect Board's & Candidate's Copy from Bank.2015 (To be filled up by the Depositor) - C.F 1842010000921 UTBI0SCTQ03 Application Form Fee*:Gen/BC – I/BC . Nursing Entrance Competitive Examination – 2015 Application Form Challan for B.08. (To be filled up by the Depositor) - C.JCECEBoard A/c . : ____________________________ Transaction ID: __________________________ Transaction ID: __________________________ Transaction ID: __________________________ NFFT / UTR No. Account Name A/c No. IFSC No.. IFSC No. : ____________________________ Mobile No.08. .II [ ] ST / SC [ ] (Tick [ √ ] which is applicable) ` 550/` 275/- * .Sc.