E C E C

JECA RANK GEN Rank SC Rank ST Rank PC Rank

Name of the Applicant (IN BLOCK LETTER)

s S

Non-refundable counselling fee of Rs.500/- in the form of a Bank Draft drawn in favour of Central Selection Committee (E&T) payable at Kolkata to be paid at the time of counselling

T C T

CENTRAL SELECTION COMMITTEE

(ENGINEERING & TECHNOLOGY) JECA COUNSELLING FORM 2011 JECA Enrolment No.

Date of Birth.

D D

MM

YY YY

Attested copy of a recent passport size photo of the applicant to be pasted within this box.

First Name Middle Name Surname Fathers / Guardians Name

Mailing address :

Pin No.
Examination Passed Or Appeared Year of Passing

Phone No.
Name of the Board / University Percentage of Marks in Aggregate Percentage of Marks in Mathematics Div. / Class

Madhyamik (10th Standard) H.S *B.A / B.SC / B.COM *B.C.A / B.E / B.Tech
FOR HONOURS GRADUATE

r * Please strikeout which ae not applicable

Examination Passed Year of Passing Or Appeared *B.A (Hons.) *B.Sc (Hons.) *B.COM (Hon.)

Name of the University

Percentage of Marks Percentage of Marks in Mathematics in Honours

DECLARATION
I declare that the statements given above are true to the best of my knowledge. I also understand that if I do not fulfil the eligibility and other criteria specified by the University / College where I have been allotted through my option for admission to MCA course, my candidature will be outright cancelled. Date: ................................

............................................................. Signature of the candidate in full

The following allotment code is the option excersied by me based on the availability of seats in the Institutions at the instant of my counselling. I will not claim any other seat in future. I understand that if I do not take admission to the allotted college / Institution within stipulated time, my allotment shall stand cancelled. I further understand that I will be required to produce all relevant original testimonials in respect of my fulfilment of eligibility and other criteria in respect of the allotted Institution as specified in the Information Brochure of JECA-2011 at the time of addmision otherwise my allotment shall stand cancelled. ALLOTMENT CODE ....................................... Signature of the Candidate in Full