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GOVERNMENT OF BIHAR

Bihar Combined Entrance Competitive Examination Board


Diploma Certificate Entrance Competitive Examination - 2018
Online Application Form for admission in Various Engineering Courses of Polytechnic Institution under Govt.
of Bihar and various Para Medical Dental (Matric Level) and Para Medical (Intermediate Level) of different
Govt. Recognized Hospitals/Institution for Session 2018

Registration No. 4180017564 Please donot send this Hard Copy to BCECE Board
PART- A

1. Course Group Applied for : PE,PM

2. Name of Candidate : RAGNI KUMARI

3. Father's Name : RAMPRABESH SHAH

4. Mother's Name : SITA DEVI

5. Date of Birth: : 17/ June /2000

6. Gender : Female

7. Reservation Category : EBC (Extremely Backward Caste)

8. Disabled Quota : No

9. Mobile No. : 9122070456 Note: Please Affix your same photo and put your full
signature in English and Hindi in spaces provided above.

10. Email ID : VERMAKR55@GMAIL.COM

11.Aadhaar Card No. : 231367005405


12. Marks of identification : A CUT MARK ON THE FACE
13. Are You Permanent Resident of Bihar? : Yes
14. Residential Eligibility :
15. Are you unable to write due to permanent loss of limbs / suffering from : N/A
Cerebral palsy :
16.(i) Do You Claim SMQ Quota? : No
16.(ii)If Yes, are you Son/Unmarried Daughter of Military Personnel? : N/A
17. Father's Annual Income : Less than 4.5 lakhs
18. District Name of the Institution of Passing/Appearing in Qualifying Exam: : GOPALGANJ
19. Exam Passed/ Appeared: : Passed
20. Percentage of Marks Obtained in Qualifying Exam, if Passed : : 70.4
21.(i) Educational Qualification/ Experience for PPE Course group: : N/A
21.(ii) ITI Name: : N/A
21.(iii) ITI Course: : N/A
21.(iv) Are you employed as Technical Supervisor/Class III or holding any : N/A
class III technical post in a registered Govt./ Semi Govt./Non Govt.
Industries/Organisation situated within 50 K.M radius from Govt. Polytechnic,
Patna-13:
21.(v) Are you producing the certificate issued by the authorized head : N/A
authority of the registered Govt. /Semi Govt./Non Govt.
industries/Organisation mentioning therein the applicants period of
Employment his work experience and sponsoring the applicants for
appearing in Entrance Examination for Four year Part time Polytechnic
Engineering course:
22. Have you completed any ANM Course? : : No

Registration No: 4180017564 Page: 1/2


23. Payment Details:
Branch Name Journal No. /Transaction No. Deposite Date Amount (in Rs.)
ONLINE DCE5abbae3e45a28 2018-03-28 20:35:18 Rs. Eight Hundred Fifty
24. Address Details:
A. Permanent Address: B. Correspondence Address:
VILL+POST -NAWADA P.S -BARAULI VILL+POST -NAWADA P.S -BARAULI
BARAULI BARAULI
NAWADA NAWADA
District: GOPALGANJ District: GOPALGANJ
State: Bihar Pin Code: 841405 State: Bihar Pin Code: 841405
Declaration by the Candidate: I RAGNI KUMARI declare that information furnished above are correct and I shall forfeit my candidature
and will be liable for legal action in case of any of them is proved to be false at any stage inclusive of admission or thereafter.

Date: .....................
Place: ..................... (Signature in English) (Signature in Hindi)

Registration No: 4180017564 Page: 2/2


GOVERNMENT OF BIHAR
Bihar Combined entrance Competitive Examination Board
Diploma Certificate Entrance Competitive Examination - 2018
Online Application Form for admission in Various Engineering Courses of Polytechnic Institution under Govt. of
Bihar and various Para Medical Dental (Matric Level) and Para Medical (Intermediate Level) of different Govt.
Recognized Hospitals/Institution for Session 2018
Registration No. 4180017564 Please donot send this Hard Copy to BCECE Board
PART- B
(For office use only)
Selected for admission(First Counselling) Selected for admission(Second Counselling) Selected for admission(Third Counselling)

Against Roll No............................................... Against Roll No............................................... Against Roll No...............................................

Reservation Category.................................... Reservation Category.................................... Reservation Category....................................

Merit Serial .................................................. Merit Serial ................................................. Merit Serial ..................................................

at....................................................(institution) at....................................................(institution) at....................................................(institution)

in...................................... (Course/Branch) in...................................... (Course/Branch) in...................................... (Course/Branch)

Signature of Signature of Controller of Signature of Signature of Controller of Signature of Signature of Controller of


the Candidate the verifying Examination the Candidate the verifying Examination the Candidate the verifying Examination
(At the time of Officer BCECEB (At the time of Officer BCECEB (At the time of Officer BCECEB
Counselling) DCECE-2018 Counselling) DCECE-2018 Counselling) DCECE-2018

1. Course Group Applied for : PE,PM

2. Name of Candidate : RAGNI KUMARI

3. Father's Name : RAMPRABESH SHAH

4. Mother's Name : SITA DEVI

5. Date of Birth: : 17/ June /2000

6. Gender : Female

7. Reservation Category : EBC (Extremely Backward Caste)

8. Disabled Quota : No

9. Mobile No. : 9122070456 Note: Please Affix your same photo and put your full signature
in English and Hindi in spaces provided above.
10. Email ID : VERMAKR55@GMAIL.COM

11. Aadhaar Card No. : 231367005405

12. Marks of identification : A CUT MARK ON THE FACE


13. Are You Permanent Resident of Bihar? : Yes
14. Residential Eligibility :
15. Are you unable to write due to permanent loss of limbs / suffering from : N/A
Cerebral palsy :
16. (i) Do You Claim SMQ Quota? : No
16. (ii) If Yes, are you Son/Unmarried Daughter of Military Personnel? : N/A
17. Father's Annual Income : Less than 4.5 lakhs
18. District Name of the Institution of Passing/Appearing in Qualifying Exam: : GOPALGANJ
19. Exam Passed/ Appeared: : Passed

Registration No: 4180017564 Page: 1/4


20. Percentage of Marks Obtained in Qualifying Exam, if Passed : : 70.4
21.(i) Educational Qualification/ Experience for PPE Course group: : N/A
21.(ii) ITI Name: : N/A
21.(iii) ITI Course: : N/A
21.(iv) Are you employed as Technical Supervisor/Class III or holding any : N/A
class III technical post in a registered Govt./ Semi Govt./Non Govt.
Industries/Organisation situated within 50 K.M radius from Govt.
Polytechnic, Patna-13:
21.(v) Are you producing the certificate issued by the authorized head : N/A
authority of the registered Govt. /Semi Govt./Non Govt.
industries/Organisation mentioning therein the applicants period of
Employment his work experience and sponsoring the applicants for
appearing in Entrance Examination for Four year Part time Polytechnic
Engineering course:
22. Have you completed any ANM Course? : : No

23. Address Details:


A. Permanent Address: B. Correspondence Address:
VILL+POST -NAWADA P.S -BARAULI VILL+POST -NAWADA P.S -BARAULI
BARAULI BARAULI
NAWADA NAWADA
District: GOPALGANJ District: GOPALGANJ
State: Bihar Pin Code: 841405 State: Bihar Pin Code: 841405
24. Educational Qualification:
School/College Passing
Level Subject Board/University Name Passing Status Percentage/CGPA
Name Year
HIGH SCHOOL Bihar School Examination
Secondary/Standard X All Subject Passed 2015 70.40
BARAULI Board
HIGH SCHOOL
Bihar School Examination
(10+2) / I.Sc./ Equivalent PCMB BARAULI Passed 2017 66.20
Board
GOPALGANJ

25.(A) Declaration of Candidate:

( )

Place: ...................................

................................................................ ................................................................
Candidate's Full Signature (in English)
Date: ................................... (Not in Capital letters)

Registration No: 4180017564 Page: 2/4


(B) Declaration of Father/Mather/Husband/Spouse/Guardian

RAGNI KUMARI

Place: ...................................

................................................................ ................................................................
Full Signature of
Date: ................................... Father/Mother/Husband/Spouse/Guardian in
English (Not in Capital letters)

26. List of Enclosure:

1. 2.

3. 4.

5. 6.

7. 8.

Registration No: 4180017564 Page: 3/4


27.
(AT THE TIME OF FIRST COUNSELLING/INTERVIEW ONLY)
(i) Full signature of the candidate (ii) L.T.I of the Candidate
(English) .......................

(Hindi) .........................

(AT THE TIME OF SECOND COUNSELLING/INTERVIEW ONLY)


(I) Full signature of the candidate (ii) L.T.I of the Candidate
(English) .......................

(Hindi) .........................

(AT THE TIME OF THIRD COUNSELLING/INTERVIEW ONLY)


(I) Full signature of the candidate (ii) L.T.I of the Candidate
(English) .......................

(Hindi) ..........................

28.
(FOR OFFICE USE OF THE CONCERNED INSTITUTE ON THE BASIS OF FIRST COUNSELLING)

Roll No. ........................................ Reservation Category .................................... Merit Serial ..................... of DCECE(PE/ PPE/
PM/ PMD)-2018 in the First Year of ............................... Course/Branch of the Institute ................................................ as He/She
fulfilled all the requirements of being admitted.

SEAL OF THE INSTITUTE SIGNATURE OF THE


DIRECTOR/PRINCIPAL

(FOR OFFICE USE OF THE CONCERNED INSTITUTE ON THE BASIS OF SECOND COUNSELLING)

Roll No. ........................................ Reservation Category .................................. Merit Serial ..................... of DCECE(PE/ PPE/
PM/ PMD)-2018 in the First Year of ............................... Course/Branch of the Institute ................................................ as He/She
fulfilled all the requirements of being admitted.

SEAL OF THE INSTITUTE SIGNATURE OF THE


DIRECTOR/PRINCIPAL

(FOR OFFICE USE OF THE CONCERNED INSTITUTE ON THE BASIS OF THIRD COUNSELLING)

Roll No........................................ Reservation Category .................................. Merit Serial ..................... of DCECE(PE/ PPE/ PM/
PMD)-2018 in the First Year of ............................... Course/Branch of the Institute ................................................ as He/She
fulfilled all the requirements of being admitted.

SEAL OF THE INSTITUTE SIGNATURE OF THE


DIRECTOR/PRINCIPAL

Registration No: 4180017564 Page: 4/4