ICR Application Form

Side - A

I.T.I. Entrance Competitive Examination - 2016

Name : ........................................................................................................................................................................................................

Father's Name : .........................................................................................................................................................................................

Address : ...................................................................................................................................................................................................

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

...................................................................................................................................... Dist. ....................................................................

State .......................................................................................................... Pin :

01. Name of the Candidate

02. Father's Name

03. Date of Birth 04. Gender 05. Category (Write the relevant code in the box)(Write the relevant code in the box)

06. S.M.Q. (Priority Code)(See back side i.e. Side-B)(See back side i.e. Side-B)

Male - MFemale - FMale - MFemale - F

Gen - 1 BC-I - 4SC - 2 BC-II - 5ST - 3ST - 3SC - 2 BC-II - 5Gen - 1 BC-I - 4YearMonthDate

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,

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)

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: __________________

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

08. Exam Centre City Code(See back side i.e. Side-B)(See back side i.e. Side-B)

First ChoiceFirst Choice Second ChoiceSecond Choice

----09. Correspondence Address

--

PIN Code District Code

(See back side, i.e. Side-B for District Code)

District CodePIN Code

010. Mobile No.

11. AADHAR No.(If available)

Pin Code & District Code

07. Handicapped

Phy. Hand.- 3 None - 4

Blindness - 1 Deafness - 2

Phy. Hand.- 3 None - 4

Blindness - 1 Deafness - 2

Pin Code & District Code

YearMonthDateDate Month Year

--------

(If available)

09. Correspondence Address

08. Exam Centre City Code07. Handicapped06. S.M.Q. (Priority Code)

05. Category04. Gender03. Date of Birth

10. Mobile No.

11. AADHAR No.

12. Your Father / Guardian annual Income (Write the relevent code)

I.T.I. Entrance Competitive Examination - 2016

(See back side, i.e. Side-B for District Code)

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.

01. Name of the Candidate

02. Father's Name

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

Side - B

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 or

I 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 or

thereafter 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:- _________________

Date:- _____ / ______ / 2016

0707

I.T.I. Entrance Competitive Examination - 2016I.T.I. Entrance Competitive Examination - 2016

070707

Bank’s Copy

Challan for I.T.I. 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 I.T.I. 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 I.T.I. 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.

Application Fee:- Application Fee:- Application Fee:-

IFS Code - UTBI0SCTQ03 IFS Code - UTBI0SCTQ03