Assam CEE 2014 - Annexure_E

5/27/2018 Assam CEE 2014 - Annexure_E

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Annexure E

APPLICATION FORM FOR ADMISSION INTO ENGINEERING COLLEGES OF ASSAM,

SESSION 2014-15

FORM- B(FOR OFFICE USE ONLY)

Serial No. ....................... Register No. ............................Category, if any, under which allotted .......................................

APPLICATION FOR ADMISSION TO ENGINEERING DEGREE COURSE

Note:

1. Application should be submitted to the Chairman, AdmissionCommittee on the date of interview as notified in the Newspaper(s)

2. No notice will be taken of any communication or document sentby a candidate after the submission of the application

3. For eligibility requirement, correct name of the course andinstitute the applicant is advised to go through the InformationBrochure.

A. Name of the Course (in order of preference):

1. ___________________________ 2. _____________________ 3. ___________________

b. Name of College (in order of preference) :

1. ___________________________ 2. _____________________ 3. ___________________

Item No. 1 to 22 to be filled up legibly in candidates handwriting in English (Refer Information Brochure)

1. Name of the Applicant : Sri/Smti ..........................................................................(in block letter)2. Sex (M/F) : M/ F3. Address for Communication : ...............................................................................................

Locality ...............................................................................

Post Office ........................................................................

Pin Code ............................

District ..................................

State .......................................

STD Code .............................. Telephone No.......................Mobile No. ...

4. Parents NameFathers Name : .......................................................................................

Mothers Name : .......................................................................................

5. Occupation of Father/Guardian : .......................................................................................6. Annual Income of Parents : ......................................................................................

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7. Permanent Home Address : .......................................................................................Locality ........................................................................

Post Office ..................................................................

Pin Code ............................

District ..........................................State ...............................................

8. Guardians Name : Sri / Smti ................................................................................9. Age on 1stAugust, 2014 : Year .................. Months ................... Days ............................10. Nationality : ..................................11. Religion : ..................................12. Mother tongue : ..................................13. Caste : ..................................14. State in which applicant is a Permanent Resident: ...........................................................15. Extra-Curricular Activities & Proficiency: ............................................................................16. University / Board / Council Registration No. : .................................................................

a. Board : ..b. Registration Number : ..c. Year of Registration : ..

17. Examination Roll No. of University /Board Council last appeared/passed: ..18. DETAILS OF EXAMINATIONS PASSED (Attach Photocopies of the Certificates)

Examination Name ofUniversity/Board/

Council etc.

Institute fromwhere passed

Year Divisionsecured Subjects

taken in the

final examHSLC/ 10th

H.S./10 + 2 orEquivalent (Sc.)

B.Sc.

19. PERCENTAGE OF MARKS OBTAINED IN QUALIFYING EXAM (Attach true copies of the Certificate)Examination Percentage of Marks obtained % age of Marks

in aggregate of

three subjects

Aggregate of all subjects

Maths Physics Chemistry Marks

secured

Out of Total

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20. Whether discontinued studies in between passing the last Examination of Board / Council/University (tick the correct option) : Yes / No

If Yes,

a)

Reason: .........................................................................................................b) Period : .........................................................................................................c) Engagement during the period:...........................................................

21. If you are not a permanent resident of Assam but your parent is in service under Govt./StatutoryOrganisation / Department Bodies, give :

a) Name of the Parent : .........................................................................................................

b) Name of the Office with Address:

.................................................................................................................................................................

c) Name of Govt./Statutory Body: ............................................................................................

d) Post held: ......................................................................................................................................

e) Period of Service: .......................................................................................................................

22. Give the name of the State /Administration, if applied against reserved seats:............................................................................

23. Whether Son/Daughter of Employee/Ex. Employee of D.T.E. Assam : Yes/No24. DECLARATION BY THE APPLICANT

I hereby declare that the above entries in the form have been filled up in my own

handwriting and the entries made are correct to the best of my knowledge and belief.

In case of

1. false/inaccurate statements given by me or in the mark-sheets and certificateattached and

2. detection of non-fulfilment of any Eligibility Criteria for admissionDirector of Technical Education has got every right to cancel my Admission to any Course

and College at any stage my Academic Career and he shall have all right to take

appropriate legal action against me for submission of false information and documents.

Date : ........................................

................................................................

Place : ........................................ Signature of the Applicant

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25. DECLARATION BY THE PARENT/GUARDIAN

In the event of my Son/Daughter/Ward Shri/Smti. ........................................................... being admitted in

any Institute shall be responsible for his/her conduct and undertake to pay his/her college dues,

hostel dues and any other expenses during his/her studentship in the college. I also undertake to

withdraw him/her from the college, should the authorities concerned decided that such withdrawal

is necessary in the interest of the college or in the event of inability to pay his/her college dues in

time or dues if any and without claiming any compensation from the Government or the college

authorities.

I certify that the particulars stated in the application by my son/daughter/ward are true to

the best of my knowledge and if it is proved that the information is fraudulent, I am liable to criminal

persecution.

...........................................................

.......................................................................

Signature of the Gazetted Officer in presence Signature of Parent / Guardian

of whom the parent/guardian signed.

Designation of the Officer.....................................................................

Seal of the Officer

FORMAT OF CERTIFICATE OF EMPLOYMENT OF APPLICANTS PARENT

(To be given by the Head of the Government or Public Officer/Organization in Assam; if the applicant if not a permanent

resident of Assam but his/her parent is working in such offices, etc. In Assam at the time of submission of application)

Certified that Shri/Smti......................................................................................... parent of the applicant Shri/Smti.

......................................................... has been serving as ................................................ under ...............................................................

since ................................ .

Address of the employer ......................................................... ........................................................................

.............................................................................................................. Signature of the employer

Date ...................................................... Designation ...............................................

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Check List of Documents along with Form-B

A. Candidates called for Counseling for Admission in Government Engineering Institutions are to bring thefollowing documents in Original for verification along with self-attested photo copies of the following,

for submission with Form B (mandatory)

1. Permanent Residence Certificate (PRC)(to be issued by D.C./S.D.O.(Civil) of concerning Dsitrict/Sub-Division)

2. The Caste/Category Certificate as mentioned in the Information Booklet (ifApplicable)

3. Admit Card of the CEE- 20144. 10thAdmit/Pass Certificate for Age Proof issued by Board/Council5. 10thMark sheet6. 12thAdmit Card7. 12thMark sheet8. Academic Gap Certificate (refer Sl. No. 20) (if applicable)9. Character Certificate from Head of the Institution last attended.10. 4 (four) copies of recent passport-size photograph.

COMPETENT AUTHORITY TO ISSUE CERTIFICATES

Candidates applying for seats against reserved quotas must furnish appropriate certificate from the

competent authorities, as mentioned in the Information Booklet.

Note.1. All original certificate and testimonials will have to be produced at the time of the

Counseling/Admission2. Any documents attached along with this form must also bear the signature of the

candidate.3. The candidate must be present in person at the time of interview.

** PLEASE NOTE:

FOR THE SESSION 2014-15, ONLINE COUNSELING MAY BE

ADOPTED FOR ADMISSION INTO THE FOLLOWING GOVERNMENT

ENGINEERING COLLEGES - (i) ASSAM ENGINEERING COLLEGE, (ii)JORHAT ENGINEERING COLLEGE, (iii) JORHAT INSTITUTE OF

SCIENCE & TECHNOLOGY, & (iv) BINESWAR BRAHMA

ENGINEERING COLLEGE, SUBJECT TO THE APPROVAL BY THE

GOVERNMENT OF ASSAM.

IN SUCH CASE, THE DETAILS OF ONLINE COUNSELING WOULD BEPUBLISHED IN THE LEADING DAILIES OF THE STATE AND WEBSITE

OF THE DIRECTORATE OF TECHNICAL EDUCATION ASSAM

(www.dteassam.in)

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For More Information of

Assam CEE

Visit

http://admission.aglasem.com/assam-cee/
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