ADMISSION COMMITTEE FOR PROFESSIONAL COURSES

L. D. College of Engineering Campus, Ahmedabad-380 015. Website : www.jacpcldce.ac.in

Admission from Diploma in Engineering Courses to Second Year (Third Semester) of Bachelor of Engineering and Technology Courses (2011-12)
Registration No. : Date : Merit No.

APPLICATION FORM

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Category

(For office use only) Instructions : 1. Read instructions carefully from the website www.jacpcldce.ac.in before filling up the application 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 are eligible to apply. 4. Form Fee Rs. 350/- is to be paid through bank counter of designeted branches of PNB upto Dt. 17/07/2011 during normal banking hours by producing bank slip (to be downloaded from website www.jacpcldce.ac.in) 5. After filling this form, submit at help centre alongwith bank challan, and xerox copy of all necessary documents as specified on page No. 3/3 on or before Dt. 17/07/2011 upto 5.00 p.m.

Affix Passport Size Photograph

1. Name of Board/Uni. : 2. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: 3. Month & Year of Passing : M M Y 4. Name of Applicant : (Surname) 5. Gender : Male Female 6. Category : (Name) Open SC ST (Fathers Name) SEBC Ex. Serviceman Y Y Y

7. Discipline from which Diploma passed : 8. P. H. Y N 9. H.S.C. Passed : 11. Mobile No. : Y N

10. Bank Challan No. : Remarks :

FOR OFFICE USE ONLY

Category Merit No. Merit Marks Total Marks Percentage Admitted At Signature of Officer
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Name and Signature of First Scrutinizer :

Name and Signature of Final Scrutinizer :

APPLICATION FORM 2011-12

(Surname) 1. Name of Applicant : 2. Male / Female : No 3. Category : (Name) (Fathers Name)

4. Are you physically Handicapped ? Yes

5. Result of Std. Xth (S.S.C.) and XIIth (H.S.C.) Science Stream Exam. S.S.C. Exam. H.S.C. Board Month & Year Marks of Theory Obtained Out of Marks with Practical Obtained Out of Board Month & Year Marks out of 500

6. Result of Diploma Courses : Board/Uni. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: Name of Discipline :
Sr. No. Courses & Subject No./Semester
Semester Course No.

Month & Year of Passing :

Name of Subject Theory Marks/ Grade Obtained Out of

(Only theory as per mark sheet of best of ten / last two semesters*)

1 2 3 4 5 6 7 8 9 10 11 12 Total.... Aggregate % C.P.I. : Theory %

* As per sub-section 1(c) of section-12 of Admission Rules, if either of the last two semester is having project / training

exclusively, then enter the theory marks of last two semester excluding the semester having project / training.
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7. 9.

Nationality : Father / Guardians Full Name : Relation with the applicant :

8. Birth Date : D

D M M Y Y

Y Y

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 my knowledge and belief. I have read the notification No. GH/SH/24/2008/PVS-102008-634-S dtd. 19/07/2008 and its amendment. I shall abide by the terms and conditions therein. In the event of suppression or distortion of any information provided in my application form, I understand that admission granted by The Admission Committee for Professional Courses, Ahmedabad, Gujarat is liable for cancellation. I also understand that the decision of the The Admission Committee for Professional Courses regarding my admission will be final and I shall abide by their decision. Further, if admitted, I promise to abide by the rules and regulations of the Institute as applicable during the course of study. I am also aware that ragging is banned and if, found guilty, I shall be liable for punishments as per rules. I abide to pay the fees as decided. I abide to pay the fees as determined by the Fee Regulatory Committee.

Date : D Place :

D M M Y Y

Y Y

Signature of Father / Guardian

Signature of Applicant

Enclosures : Please
1. 2. 3. 4. 5. 6. 7. 8. 9.

tick mark in the box where copies are attached :

Xth (S.S.C.) Mark Sheet .................................................................................................................................... XIIth (H.S.C.) Mark Sheet .................................................................................................................................. Best of Ten / Last two Semester Mark Sheet / C.P.I. Certificate (whatever is applicable) ............................... Diploma passing certificate from TEB / Head of Institute / University .............................................................. School Leaving Certificate ................................................................................................................................ Caste Certificate from competent authority (for SC/ST/SEBC category) ......................................................... Non creamylayer certificate issued after 1st April, 2010 (For SEBC category only) ........................................ PH Certificate from the competent authority ..................................................................................................... Ex/In Serviceman Certificate from the competent authority .............................................................................
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Commissionerate of Technical Education, Gujarat State Admission Committee For Professional Courses (ACPC)
Bank Challan of Application Fee for Admission in Diploma to Degree Engineering
To be filled by Candidate Name Board : : : To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only. Bank Seal : Date :

ACPC Copy

MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.

Bank Transaction No. :

Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cut From Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commissionerate of Technical Education, Gujarat State Admission Committee For Professional Courses (ACPC)
Bank Challan of Application Fee for Admission in Diploma to Degree Engineering
To be filled by Candidate Name Board : : : To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only. Bank Seal : Date :

Candidate Copy

MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.

Bank Transaction No. :

Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cut From Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commissionerate of Technical Education, Gujarat State Admission Committee For Professional Courses (ACPC)
Bank Challan of Application Fee for Admission in Diploma to Degree Engineering
To be filled by Candidate Name Board : : : To be filled by Bank PNB Bank A/c. No. : 6700000100002691 Amount of Fee Rs. 350/- in cash only. Bank Seal : Date :

Bank Copy

MPEC/Non MPEC/Reg. No. / Seat No./ Enrollment No.

Bank Transaction No. :

Application Fee can be paid at any designated branches of PNB on or before 17/07/2011 during banking hours.

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