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ICR Application Form
Side - A
Vocational/I.T.I. to Diploma Entrance Competitive Examination - 2016
Name : ........................................................................................................................................................................................................
Father's Name : .........................................................................................................................................................................................
Address : ...................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................... Dist. ....................................................................
State .......................................................................................................... Pin :
1. Name of the Candidate (as per 10th class records)
2. Father's Name (as per 10th class records)
3. Date of Birth3. Date of Birth 4. Gender4. Gender 5. Category5. Category (Write the relevant code in the box)(Write the relevant code in the box)
6. Handicapped
Male - MFemale - FMale - MFemale - F
Gen - 1 BC-I - 4SC - 2 BC-II - 5ST - 3
Blindness - 1 Deafness - 2
ST - 3SC - 2 BC-II - 5Gen - 1 BC-I - 4
Phy. Hand.- 3 None - 4
Blindness - 1 Deafness - 2
Phy. Hand.- 3 None - 4
7. Mobile No.
YearMonthDate
12. 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
13. Application Fee details :- If candidate has submitted by Demand Draft
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 Bank 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)
14. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN
15. Signature of the Candidate
16. Paste Photograph within provided space 17. 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: __________________
(Please ensure that CHALLAN Board's Copy is attached with Application Form)
0
(See back side i.e. Side - B for Group Code)
6. Handicapped
11. Group Code of Vocational Course or I.T.I. Trade10. M.C.Q. Quota(Muslim Community Quota)
Yes - 1No - 2No - 2Yes - 1
2. Father's Name (as per 10th class records)
1. Name of the Candidate (as per 10th class records)
If candidate has submitted through Bank CHALLAN
1. Demand Draft No.: _______________________
3. Deposit Date : _____ / _____ / 2016
2. Demand Draft Amount: ____________________
1. Demand Draft No.: _______________________
2. Demand Draft Amount: ____________________
If candidate has submitted by Demand Draft(Please ensure that Demand Draft in ORIGINAL is attached with Application Form)
8. AADHAR No.(If available)
10. M.C.Q. Quota 11. Group Code of Vocational Course or I.T.I. Trade
12. Your Father / Guardian annual Income (Write the relevent code)
13. Application Fee details :-
14. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN
15. Signature of the Candidate
16. Paste Photograph within provided space 17. Left thumb impression
(See back side i.e. Side - B for District Code)9. Correspondence Address PIN & District Code
--
PIN Code District CodeDistrict CodePIN Code
9. Correspondence Address PIN & District Code
Vocational/I.T.I. to Diploma Entrance Competitive Examination - 2016
3. Deposit Date : _____ / _____ / 20163. Deposit Date : _____ / _____ / 2016
7. Mobile No.
8. AADHAR No.
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.
Side - B Vocational/I.T.I. to Diploma Entrance Competitive Examination - 2016
(11) Course's/Trade's name and their Group Code
Course's Name
Fitter, Turner, Mechanist, Mech. Motor Vehicle, Machinist Grinder, Mech. Ref. & Air ConditioningDraftsman Mechanical, Instrument Mech. Automobile Engg. & Tech., Production & Manufacturing
Electrical, Wireman, Electroplater, Electrician, Electrical Domestic Appliances
Surveyor, Draftsman Civil
Mech. General Electronics, Mech. Radio & TV, Mech. Consumer Electronics, Mech. Industrial
Group Code
1
1. Name of the Candidate: _________________________________________________________________
2. Father's Name: ________________________________________________________________________
3. Mother's Name: ________________________________________________________________________
4. Permanent Address: ____________________________________________________________________
________________________________________________________________________________________
Dist. : _________________________________ State: ____________________________________________
Tel. No. / Mobile No.: PIN No. :
5. Visible identification mark of the Candidate: __________________________________________________
6. Date of Birth
YearMonthDateDate Month Year
--------
7. Category (For statistical purpose) [ ]: GEN SC ST BC-I BC-II
8. Gender [ ]: Male Female
9. Declaration of the Candidate:
1. Name of the Candidate: _________________________________________________________________
2. Father's Name: ________________________________________________________________________
3. Mother's Name: ________________________________________________________________________
________________________________________________________________________________________
Dist. : _________________________________ State: ____________________________________________
Tel. No. / Mobile No.:
YearMonthDateDate Month Year
--------
GEN SC ST BC-I BC-II
Male Female
PIN No. :0
I hereby declare that informations furnished above are correct and all certificates in ORIGINAL are lying with me orI am able to procure required certificates and will be produced at the time of COUNSELLING. I shall forfeit my cand-idatures as well as liable for legal action in case any of them is proved to be false at any stage of ADMISSION orthereafter or if I will not produce relevant required ORIGINAL certificates.
11. Candidate's signature
4. Permanent Address: ____________________________________________________________________
5. Visible identification mark of the Candidate: __________________________________________________
6. Date of Birth
7. Category (For statistical purpose) [ ]:
8. Gender [ ]:
9. Declaration of the Candidate:
10. Father's / Guardian's signature10. Father's / Guardian's signature 11. Candidate's signature
Date:- _____ / ______ / 2016
Place:- _________________
9
Electonics, Electronics Mechanic, Electronics Technology, Radio TV Technician
I.T. & E.S.M., Mech. Computer Hardware, Computer Science
Mining Geology
23
4
56
(11) Course's/Trade's name and their Group Code
Course's Name
Fitter, Turner, Mechanist, Mech. Motor Vehicle, Machinist Grinder, Mech. Ref. & Air ConditioningDraftsman Mechanical, Instrument Mech. Automobile Engg. & Tech., Production & Manufacturing
Electrical, Wireman, Electroplater, Electrician, Electrical Domestic Appliances
Surveyor, Draftsman Civil
Mech. General Electronics, Mech. Radio & TV, Mech. Consumer Electronics, Mech. Industrial
Group Code
1
Electonics, Electronics Mechanic, Electronics Technology, Radio TV Technician
I.T. & E.S.M., Mech. Computer Hardware, Computer Science
Mining Geology
23
4
56
9
Vocational/I.T.I. to Diploma Entrance Competitive Examination - 2016
Date:- _____ / ______ / 2016
Bank’s Copy
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
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
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.
Application Fee:- Application Fee:- Application Fee:-
IFS Code - UTBI0SCTQ03 IFS Code - UTBI0SCTQ03
Challan for Vocational / I.T.I. to Diploma Entrance Competitive Examination – 2016 Application Form
Challan for Vocational / I.T.I. to Diploma Entrance Competitive Examination – 2016 Application Form
Challan for Vocational / I.T.I. to Diploma Entrance Competitive Examination – 2016 Application Form