Form no. ....................

(Filled by Institute)

JOINT ENTRANCE EXAMINATION COUNCIL, U.P., 1, Guru Govind Singh Marg, Bansmandi Chauraha, Charbagh, Lucknow

SPOT COUNSELING - 2016

REGISTRATION FORM

NAME OF POLYTECHNIC / INSTITUTE : …..................................................................................

1- PARTICULARS OF THE CANDIDATE

Roll No. : Application No. : Group :

Obtain Marks : ......../400 Open Rank : ........................ (Attach Score Card of JEEC)

Name of Candidate : ....................................................................... Father's Name .................................................

Date of Birth (as per High School Certificate) : dd /mm /yyyy Gender : Male/Female Contact No. .....................

2- DETAILS OF QUALIFYING EXAMINATION PASSED : (Attach Photocopy of Relevant documents)

Name of qualifying examination - High School / Intermediate / Graduate / Diploma / ITI.

Obtained % of Marks in Qualifying Examination : .............. Year of Passing : .......................

College/Institute :.................................................... Board/University : .............................. State : ..........................

3- CHOICES (in order of priority): Candidate must ensure that given choices/vacancy exists in the Polytechnic/Institute. Name of Branches :

1- .................................................................... 5- .................................................................................

2- ..................................................................... 6- .................................................................................

3- ...................................................................... 7- ..................................................................................

4- ...................................................................... 8- ............................................. ....................................

4-DECLARATION : I am not admitted/admitted seat in Government/Aided Polytechnic ……………………………….................Branch Name…………………….. (If allotted attach Allotment Letter)

I hereby declare that the above statements are correct. I have gone through the contents of information Brochure Vivran Pustika - 2016 and eligibility criteria prescribed therein. I read instructions and procedures adopted for allotment of branch through Spot Counseling in the

institute. I am fully aware of the restrictions on qualifying examination, obtained percentage and essential subjects, age, category and sex for

admission to institutions/Polytechnics. I am not applying in any other Institute / Polytechnic for Spot Counseling - 2016.

I have taken admission in Government/Aided Polytechnic and deposited prescribed fees as per rule.

If my statement found false/incorrect about fees or any other detail, my allotment to this Polytechnic can be cancelled at any stage, I

will not make any claim. (Strike out statements not concerned)

Date : .............................

(Signature of Candidate)

For Office Use : Documents :

Result :

Merit position in the Polytechnic / Institute - ………………………………………………………………………………….

Allotted : / Allotted Branch - …………………………………………………………………….

Name & Signature of Spot Counseling Committee

1- …............................. 2- …............................. 3- …............................. 4- …............................. 5- ….............................

Receiving : (To be given to Candidate) Form no. .................... (Filled by Institute)

1- Application No. : …………………………………….. Roll No. : …………………………

2- Name : ………………………………………………… Father’s Name : ………………………………….

3- Obtain Marks : ………………………………………… Open Rank : ……………………………

Signature

College seal

Paste identical

Self Attested

Photograph of the

Candidate

uploaded on

Application Form

(i) Admit Card

(i) Rank Card

(iii) Mark sheet, Certificate of Qualifying Examination

(iv) Domicile Certificate/Employee Certificate (if required)

(v) Allotment Letter for Security Fee (if available)

(vi) Photograph

Yes No

FORMAT FOR INSTITUTE (SPOT COUNSELING)

(email to upjeec@gmail.com on 10-08-2016)

1- Name of Institute :

2- Number of Candidates reported at Polytechnic/Institute :

3- Seat Detail : Sl.

No.

Name of Branch Group Number

of

Vacant

Seat

Number

of

Candidates

applied

Number

of

Candidate

Selected

Number

of

Candidate

for

waiting

list

Number

of

Candidates

taken

Admission

Remark

4- Name, Designation, Mobile No. of the Observer (Appointed by Administration) :

5- Any other matter.

Signature :

Name :

Seal :

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