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 (2012-13)
(For office use only)

APPLICATION FORM

Registration No. : Date :

Category

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. 2011 or April/May 2012, from TEB/Universities/Institutions situated in Gujarat State are eligible to apply. 4. Form Fee Rs. 350/- (non refundable) is to be paid through bank counter of designeted branches of PNB upto Dt. 27/07/2012 during normal banking hours by producing bank challan (to be downloaded from website www.jacpcldce.ac.in) 5. After filling this form, submit at help centre alongwith bank challan and photo copy of all necessary documents and original for verification, as specified on page No. 3/4 on or before Dt. 27/07/2012 upto 5 p.m. 6. Please collect Registration Slip bearing PIN. 7. Candidate is instructed that the 14 digit unique PIN printed on Acknowledgement Slip is required in every stage of admission. Please do not disclose / share this PIN with anyone and keep it at a safe place.

Affix Passport Size Photograph

(To be filled by Candidate)

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. Diploma passing discipline : 8. P. H. Y N 9. H.S.C. Passed : Y N 10. Bank Challan No. :

11. Mobile No. :

(Mandatory)

12. E-mail :

Remarks :

FOR OFFICE USE ONLY

Category Merit No. Merit Marks Total Marks Percentage Admitted At Signature of Officer
[1/4]

Name and Signature of First Scrutinizer :

Name and Signature of Final Scrutinizer :

APPLICATION FORM 2012-13

(Surname) 1. Name of Applicant : 2. Male / Female : No Marks out of 500 3. Category : (Name) (Fathers Name)

4. Are you physically Handicapped ? Yes Exam. S.S.C. Exam. H.S.C. Board Board

5. Result of Std. Xth (S.S.C.) and XIIth (H.S.C.) Science Stream Month & Year

Month & Year

Marks of Theory Obtained Out of

Marks with Practical Obtained Out of

6. Result of Diploma Courses : Board/Uni. MPEC Registration No. / Non MPEC No. / Seat No. /Enrollment No.: Name of Discipline : Month & Year of Passing :

* As per Admission Rule-12(1) A candidate who has passed the qualifying examination having project/training in the last or preceding semester or both then the marks/STPI obtained by such candidate in such semester/semesters shall not be considered for the purpose of merit list and the theory marks/STPI obtained in those last two semesters having theory subjets only shall be considered for the purpose of merit list. Please refer rule-12(1) above before filling below table.
Sr. No. Board / Unviersity / Institute Please fill Data as per your Examination Board / Unviersity / Institute.

1 2 3 4 5 6 7 8

GTU TEB Non-MPEC TEB MPEC MSU Nirma IGTR CIPET DDIT

STPI1 Aggregate Marks Theory Marks Aggregate Marks Theory Marks Aggregate Marks Theory Marks Aggregate Marks Theory Marks Aggregate Marks Theory Marks Aggregate Marks Theory Marks Aggregate Marks Theory Marks
[2/4]

STPI2 / out of / out of / out of / out of / out of / out of / out of / out of / out of / out of / out of / out of / out of / out of

ACPC CPI Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage

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. :

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 amendments. 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.

DECLARATION BY THE CANDIDATE

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 :

10th (S.S.C.) Mark Sheet ................................................................................................................................... 12th (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, 2012 (For SEBC category only) ........................................ PH Certificate from the competent authority ..................................................................................................... Ex/In Serviceman Certificate from the competent authority .............................................................................
[3/4]

Commissionerate of Technical Education, Gujarat State Admission Committee For Professional Courses (ACPC)
Bank Challan of Application Fee for Admission in Diploma to Degree Engineering 2012-13 To be filled by Candidate Name Board : : : To be filled by Bank PNB Bank A/c. No. : 6700000100008747 Amount of Fee Rs. 350/- in cash only. Bank Seal Date : :

ACPC Copy

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

Bank Challan No. :

Application Fee can be paid at any designated branches of PNB on or before 27/7/2012 during banking hours. Application Form Fee Rs. 350/- is not refundable.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 2012-13 To be filled by Candidate Name Board : : : To be filled by Bank PNB Bank A/c. No. : 6700000100008747 Amount of Fee Rs. 350/- in cash only. Bank Seal Date : :

Candidate Copy

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

Bank Challan No. :

Application Fee can be paid at any designated branches of PNB on or before 27/7/2012 during banking hours. Application Form Fee Rs. 350/- is not refundable.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 2012-13 To be filled by Candidate Name Board : : : To be filled by Bank PNB Bank A/c. No. : 6700000100008747 Amount of Fee Rs. 350/- in cash only. Bank Seal Date : :

Bank Copy

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

Bank Challan No. :

Application Fee can be paid at any designated branches of PNB on or before 27/7/2012 during banking hours. Application Form Fee Rs. 350/- is not refundable.

[4/4]