APPLICATION FEE INR 350/- [NON-REFUNDABLE]

COMMISSIONERATE OF TECHNICAL EDUCATION, GUJARAT STATE
Admission Committee for Professional Courses (ACPC)

(Constituted under Section 4 of the Gujarat Professional Technical Educational Colleges
or Institutions (Regulation of Admission and Fixation of Fees) Act. 2007 (Guj.2 of 2008)

First Floor, ACPC Building, L. D. College of Engineering Campus, Navrangpura, Ahmedabad-380 015, Gujarat, India

APPLICATION FORM FOR ADMISSION OF CANDIDATES WHO HAVE PASSED QUALIFYING
EXAMINATION AS WELL AS APPEARED IN JEE MAIN 2013 FROM OUTSIDE GUJARAT TO FIRST
YEAR DEGREE COURSES OF ENGINEERING / TECHNOLOGY IN GUJARAT STATE.
(Select appropriate check box with )

[A] PERSONAL INFORMATION OF THE CANDIDATE
1.

Name in Full (Capital Letters)

2.

Gender :

3.

Date of Birth :

4.

Place of Birth : CITY

Male

Affix Recent
Passport Size
Photograph of
candidate with
Signature

Female
–

–

[DD–MM–YYYY]
STATE

COUNTRY

PIN/ZIP

5.

Nationality:

6.

Contact Address of Candidate :
Address for
Correspondence

Phone/Mobile No.
with STD Code

Fax No.
E-mail ID

7.

Name of Parent / Guardian :

8.

Relationship with Candidate :

[B] HSC / EQUIVALENT EXAMINATION DETAILS :
1.

Qualifying Examination (HSC / Equivalent Examination)
Name of
Examination

Name of
School/College

Place of School with Name of Board/ Month & Year
Country, if any
University
of Passing

[1]

Medium of
Instruction

2.

Examination Seat No. :

3.

Marks in Qualifying Examination : (If marks are in Grades, get equivalent marks from the Authority before filling)
Sr.
No.

4.

Theory Marks

Name of
the Subject

Practical Marks

Sr.
No.

Obtained Out of Obtained Out of

1

Mathematics

6

English

2

Physics

7

PCM % of Marks

3

Chemistry

8

Grand Total

4

Biology

9

Aggregate % of
XIIth Marks

5

Computer

Marks
Obtained

1

Name of
the Subject

Marks
Obtained

Sr.
No.

Out of

Mathematics
3

2

Grand Total

Name of
the Subject

Marks
Obtained

Out of

Aggregate %
of Xth Marks

Details of JEE Main 2013 :
Application No. :

Roll No. :
Sr.
No.

Name of
the Subject

1

Mathematics

2

Physics

3

Chemistry

Marks Obtained

[C] PARTICULARS OF FEE
1.

Amount INR :

2.

DD No. :

Note :

Out of

Marks in Xth (S.S.C.) Examination :
Sr.
No.

5.

Name of
the Subject

(Non Refundable)

350/-

3.

DD Date :

4.

Bank Name :

(1) Processing Fees (non-refundable) by DD of Amount INR 350/- for all the candidates.
(2) DD should be in favour of “Member Secretary, ACPC” payable at Ahmedabad.

[D] DECLARATION BY CANDIDATE :
I do hereby declare that all the paritculars indicated above are true and correct to the best of my knowledge and
belief. I have read the Admission Rules and Information Brochure, and I shall abide by all the rules and other
terms and conditions for admission. I understand that my admission will be provisional and in the event of my
candidature being found ineligible at a later date, I will be denied admission and, if already admitted, my
admission will stand cancelled. I also udnerstand that the decision of the Admission Committee regarding my
admission shall be final and I shall be liable by its decision. I am also aware that ragging is banned and if, found
guilty, I shall be liable for punishments under the rules. I abide to pay the fees as determined by the Fee
Regulatory Committee / State Govt.

Singature of Candidate

Date :
Place :

Singature of Parent / Guardian

Note : Attach self-attested copies of all the necessary documents / testimonials with this form.

[2]