(i)

Part - B

GOVERNMENT OF BIHAR

BIHAR COMBINED ENTRANCE COMPETITIVE EXAMINATION BOARD
Application Form for Under Graduate Medical Counselling - 2013 for admission to
MBBS on the Basis of NEET (UG) - 2013
( For Office use only )
REGISTRATION NO. FOR UGMAC-2013
ROLL NO.
CATEGORY
STATE RANK (For Bihar)
STATE CATEGORY RANK (For Bihar)
Selected for admission,
Against Roll No. ………………....................… Category ......……................…………. State Rank (for Bihar)
…………………………………… State Category Rank (for Bihar) .................................................................................... at
………………...................................……………… (Institution) in ………...........................…………………… (Course).

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

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

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

Signature of the Candidate

Signature of the
Verifying Officer UGMAC-2013

Controller of Examination
BCECEB

(At the time of Counselling)
Date ...........................
( To be filled in by the Candidate in his own handwriting in capital letters except Signature and Declaration )
1.

ROLL NO. :

2.

FULL NAME :

3.

SEX (Male / Female) :

4.

DATE OF BIRTH :

1

9
PHOTOGRAPH

Date
5.

CATEGORY :
(GEN/SC/ST/EBC/BC)

6.

Do you claim Disable Quota ?
(DQ) [Yes/No]

Month

Year

Paste Passport size photograph
of the candidate, identical to one
as used preparing Admit Card
of NEET (UG)-2013

Countersignature of Father / Mother / Husband / Guardian ..........................................................
7.

FATHER'S NAME :

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8.

ADDRESS
(a) Correspondence :

PIN Code :

(b) Permanent Address
of Residence :

PIN Code :

9.

Educational Qualifications :—
(a)

Level

Name of
Examination

Name of the School/
College including District in
which it is located

a) Name of the Board /
University
b) Certificate Number

Secodnary/

a)

Standard X

b)

Year of Passing/
appearing

a)

I.Sc. / XII /
(10+2)

b)
a)

Higher
b)

(b)

Subject in

Marks

Total

I.Sc./10+2 Exam

Obtained

Marks

I. English

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

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

II. Physics

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

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

III. Chemistry

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

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

IV. Maths

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

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

V. Biology

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

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

10. Are you permanent Resident of Bihar (Yes / No) :

% of Marks obtained in
(Phy+Chem+Maths)

........... %

(Phy+Chem+Bio)

........... %

(English)

...........%

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10. Declaration of the Candidate (Not in Capital letters) :

"I, ................................................................................... son/daughter of Sri ...................................................................................
declare that : (a) Information furnished above are correct and in case any of them is proved to be false or forged at any stage of
UGMAC-2013 and my admission to and / or stay in the Institute, I shall be liable (i) to lose my candidature for admission on the
basis of UGMAC-2013, (ii) for expulsion from the institute if admitted and (iii) for appropriate legal action. (b) In the event of
my being admitted to any of the above Institutions, I shall abide by all the rules and regulations of the Institute and the
University concerned."
Repeat below in your own handwriting the above mentioned declaration as an undertaking and put your signature in
English & Hindi at the specified spaces.
"--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------"

Place : ____________
Date : _____________

11.

Full Signature of the Candidate

Full Signature of the Candidate in ENGLISH

in HINDI

(Not in capital letter)

LIST OF ENCLOSURES :
1. .....................................................................................

2. .....................................................................................

3. .....................................................................................

4. .....................................................................................

5. .....................................................................................

6. .....................................................................................

7. .....................................................................................

8. .....................................................................................

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12.

(i)

(ii)

13.

(AT THE TIME OF COUNSELLING ONLY)

Full Signature of the Candidate :

(English)

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

(Hindi)

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

L.T.I. of the Candidate :

(FOR OFFICE USE OF THE CONCERNED INSTITUTE)

Admit Roll no............................................................................................. Category ................................................................ State
Rank for Bihar ..................................................................... State Category Rank for Bihar ............................................. of NEET
(UG)-2013 in the First Year of ................................................................................ Course of this Institute as He / She fulfilled all
the requirements for being admitted.

SEAL OF THE INSTITUTE

SIGNATURE OF THE
PRINCIPAL / DIRECTOR

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