ICR Application Form Side - A Polytechnic Entrance Competitive Examination - 2016 Name : ........................................................................................................................................................................................................ Father's Name : ......................................................................................................................................................................................... Address : ................................................................................................................................................................................................... ................................................................................................................................................................................................................... ...................................................................................................................................... Dist. .................................................................... State .......................................................................................................... Pin : 1. Name of the Candidate (as per 10th calss records) 2. Father's Name (as per 10th calss records) 2. Father's Name (as per 10th calss records) 1. Name of the Candidate (as per 10th calss records) 3. Date of Birth 3. Date of Birth 4. Gender 4. Gender 5. Category 5. Category (Write the relevant code in the box) (Write the relevant code in the box) 6. MCQ Quota 6. MCQ Quota 7. S.M.Q. (Priority Code) (See back side i.e. Side-B) (See back side i.e. Side-B) Male - M Female - F Male - M Female - F Gen - 1 BC-I - 4 SC - 2 BC-II - 5 ST - 3 ST - 3 SC - 2 BC-II - 5 Gen - 1 BC-I - 4 Yes - 1 No - 2 No - 2 Yes - 1 Year Month Date 13. Your Father / Guardian annual Income (Write the relevent code) Less than Rs. 2,00,001 - 1 In between Rs. 2,00,001 to Rs. 4,50,000 - 2 In between Rs. 4,50,001 to Rs. 10,00,000 - 3 Above Rs. 10,00,001 - 4 14. Application Fee details :- If candidate has submitted by Demand Draft, 1. Demand Draft No. : __________________ 2. Demand Draft Amount : ______________ 3. Demand Draft Date : _____ / _____ / 2016 In between Rs. 4,50,001 to Rs. 10,00,000 - 3 Above Rs. 10,00,001 - 4 Less than Rs. 2,00,001 - 1 In between Rs. 2,00,001 to Rs. 4,50,000 - 2 If candidate has submitted through CHALLAN 1. Transaction ID: _________________________ 3. Deposit Date : _____ / _____ / 2016 2. Application Fee Amount: __________________ (Please ensure that CHALLAN Board's Copy is attached with Application Form) (Please ensure that Demand Draft in ORIGINAL is attached with Application Form) 15. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN 16. Signature of the Candidate 17. Paste Photograph within provided space 18. Left thumb impression Paste (Do not staple) your Non-attested Photograph Date Month Year -- -- -- -- Registration No. (Office use only) 1. Transaction ID: _________________________ 2. Application Fee Amount: __________________ 1. Demand Draft No. : __________________ 2. Demand Draft Amount : ______________ (Please ensure that Demand Draft in ORIGINAL is attached with Application Form) (Please ensure that CHALLAN Board's Copy is attached with Application Form) If candidate has submitted by Demand Draft, If candidate has submitted through CHALLAN Polytechnic Entrance Competitive Examination - 2016 3. Demand Draft Date : _____ / _____ / 2016 3. Deposit Date : _____ / _____ / 2016 9. Exam Centre City Code (See back side i.e. Side-B) (See back side i.e. Side-B) First Choice First Choice Second Choice Second Choice -- -- 10. Correspondence Address -- PIN Code District Code (See back side i.e. Side - B for District Code ) District Code PIN Code 0 11. Mobile No. 12. AADHAR No. (If available) Pin Code & District Code 8. Handicapped Phy. Hand.- 3 None - 4 Blindness - 1 Deafness - 2 Phy. Hand.- 3 None - 4 Blindness - 1 Deafness - 2 7. S.M.Q. (Priority Code) 8. Handicapped 9. Exam Centre City Code 11. Mobile No. 12. AADHAR No. 13. Your Father / Guardian annual Income (Write the relevent code) 10. Correspondence Address Pin Code & District Code Year Month Date Date Month Year -- -- -- -- (If available) 14. Application Fee details :- 15. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN 16. Signature of the Candidate 17. Paste Photograph within provided space 18. Left thumb impression Note:- Don't enclose any type of Certificates / Documents along with the form, except the requisite DD / Challan. Note:- Don't enclose any type of Certificates / Documents along with the form, except the requisite DD / Challan. (See back side i.e. Side - B for District Code )
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Name : ........................................................................................................................................................................................................
Father's Name : .........................................................................................................................................................................................
13. Your Father / Guardian annual Income (Write the relevent code)
Less than Rs. 2,00,001 - 1 In between Rs. 2,00,001 to Rs. 4,50,000 - 2
In between Rs. 4,50,001 to Rs. 10,00,000 - 3 Above Rs. 10,00,001 - 4
14. Application Fee details :- If candidate has submitted by Demand Draft,
1. Demand Draft No. : __________________
2. Demand Draft Amount : ______________
3. Demand Draft Date : _____ / _____ / 2016
In between Rs. 4,50,001 to Rs. 10,00,000 - 3 Above Rs. 10,00,001 - 4
Less than Rs. 2,00,001 - 1 In between Rs. 2,00,001 to Rs. 4,50,000 - 2
If candidate has submitted through CHALLAN
1. Transaction ID: _________________________
3. Deposit Date : _____ / _____ / 2016
2. Application Fee Amount: __________________
(Please ensure that CHALLAN Board's Copy is attached with Application Form)(Please ensure that Demand Draft in ORIGINAL is attached with Application Form)
15. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN
16. Signature of the Candidate
17. Paste Photograph within provided space 18. Left thumb impression
Paste (Do not staple)your Non-attested
Photograph
Date Month Year
--------
Registration No.(Office use only)
1. Transaction ID: _________________________
2. Application Fee Amount: __________________
1. Demand Draft No. : __________________
2. Demand Draft Amount : ______________
(Please ensure that Demand Draft in ORIGINAL is attached with Application Form) (Please ensure that CHALLAN Board's Copy is attached with Application Form)If candidate has submitted by Demand Draft, If candidate has submitted through CHALLAN
3. Demand Draft Date : _____ / _____ / 2016 3. Deposit Date : _____ / _____ / 2016
9. Exam Centre City Code(See back side i.e. Side-B)(See back side i.e. Side-B)
First ChoiceFirst Choice Second ChoiceSecond Choice
----
10. Correspondence Address
--
PIN Code District Code
(See back side i.e. Side - B for District Code )
District CodePIN Code
011. Mobile No.
12. AADHAR No.(If available)
Pin Code & District Code
8. Handicapped
Phy. Hand.- 3 None - 4
Blindness - 1 Deafness - 2
Phy. Hand.- 3 None - 4
Blindness - 1 Deafness - 2
7. S.M.Q. (Priority Code) 8. Handicapped 9. Exam Centre City Code
11. Mobile No.
12. AADHAR No.
13. Your Father / Guardian annual Income (Write the relevent code)
10. Correspondence AddressPin Code & District Code
YearMonthDateDate Month Year
--------
(If available)
14. Application Fee details :-
15. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN
16. Signature of the Candidate
17. Paste Photograph within provided space 18. Left thumb impression
Note:- Don't enclose any type of Certificates / Documents along with the form, except the requisite DD / Challan.Note:- Don't enclose any type of Certificates / Documents along with the form, except the requisite DD / Challan.
(See back side i.e. Side - B for District Code )
Side - B Polytechnic Entrance Competitive Examination - 20161. Name of the Candidate: _________________________________________________________________
Challan for Polytechnic Entrance Competitive Examination – 2016 Application
It must be deposited in United Bank of India
A/c No. - 1842010000921 IFS Code - UTBI0SCTQ03
Application Fee:-
Gen/BC – I/BC - II [ ] ` 800/-ST / SC [ ] ` 400/-(Tick [ √ ] which is applicable)
(To be filled up by the Depositor)
Category (mention your category): __________
Father's Name: ________________________
______________________________________
Date of Birth: ___________________________
Mobile No. : ____________________________
Transaction ID: __________________________
NFFT / UTR No. (In case of IFSC):
_________________________
Deposit Date: ____ / ____ / 2016
Signature of Authorized Signatory & Depositor Seal
Board’s Copy
Challan for Polytechnic Entrance Competitive Examination – 2016 Application
It must be deposited in United Bank of India
A/c No. - 1842010000921
Application Fee:-
Transaction ID: __________________________
NFFT / UTR No. (In case of IFSC):
_________________________
Deposit Date: ____ / ____ / 2016
Signature of Authorized Signatory & Depositor Seal
Candidate’s Copy
Challan for Polytechnic Entrance Competitive Examination – 2016 Application
It must be deposited in United Bank of India
A/c No. - 1842010000921
Application Fee:-
Transaction ID: __________________________
NFFT / UTR No. (In case of IFSC):
_________________________
Deposit Date: ____ / ____ / 2016
Signature of Authorized Signatory & Depositor Seal
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Instruction for Candidate:- Submit the requisite Application fee and collect Board's & Candidate's Copy from Bank. Send the Board's Copy with the Application Form.
Gen/BC – I/BC - II [ ] ` 800/-ST / SC [ ] ` 400/-(Tick [ √ ] which is applicable)
Gen/BC – I/BC - II [ ] ` 800/-ST / SC [ ] ` 400/-(Tick [ √ ] which is applicable)
Candidate’s Name: ______________________
______________________________________
(To be filled up by the Depositor)
Category (mention your category): __________
Father's Name: ________________________
______________________________________
Date of Birth: ___________________________
Mobile No. : ____________________________
Candidate’s Name: ______________________
______________________________________
(To be filled up by the Depositor)
Category (mention your category): __________
Father's Name: ________________________
______________________________________
Date of Birth: ___________________________
Mobile No. : ____________________________
Candidate’s Name: ______________________
______________________________________
Instruction for Candidate:- Submit the requisite Application fee and collect Board's & Candidate's Copy from Bank. Send the Board's Copy with the Application Form.