Side - A

SECTION - A

B.Sc. Nursing Entrance Competitive Examination - 2015

Application Form

Registration No.
(Office use only)

1. Name of the Candidate (as per 10th class records)

2. Father's Name (as per 10th class records)

3. Husband Name (if Married)

4. Date of Birth
Date

Month

--

5. Gender
Male - M
Female - F

Year

--

7. Handicapped
Blindness - 1 Deafness - 2
Phy. Hand.- 3 None
- 4

8. Mobile No.

6. Category (Write the relevant code in the box)

Gen - 1
BC-I - 4
SC - 2
BC-II - 5
ST - 3

9. AADHAR No.
(If available)

10. Subject Group Code applying for

11. Correspondence Address PIN & District Code

B.Sc. Nursing (Basic Course)
- 1
B.Sc. Nursing (Post Basic Course) - 2

(See back side for District Code i.e. Side-B)

-PIN Code

12. Application Fee details :If candidate has submitted by Demand Draft,
(Please ensure that Demand Draft in ORIGINAL is attached with Application Form)

District Code

If candidate has submitted through CHALLAN

(Please ensure that CHALLAN Board's Copy is attached with Application Form)

1. Demand Draft No. : __________________

2. Demand Draft Amount : ______________

1. Transaction ID: _________________________

2. Application Fee Amount: __________________

3. Demand Draft Date : _____ / _____ / 2015

3. Deposit Date : _____ / _____ / 2015

SECTION - B

13. Address for Correspondence (IN CAPITAL LETTERS) USE ONLY BLACK PEN

Name : ........................................................................................................................................................................................................
Father's Name : .........................................................................................................................................................................................
Address : ...................................................................................................................................................................................................
...................................................................................................................................................................................................................

Paste (Do not staple)

your Non-attested
Photograph

...................................................................................................................................... Dist. ....................................................................

State ..........................................................................................................

Pin :

15. Paste Photograph within provided space 16. Left thumb impression

14. Signature of the Candidate

Side - B

B.Sc. Nursing Entrance Competitive Examination - 2015

1. Name of the Candidate: _________________________________________________________________

2. Father's Name: ________________________________________________________________________
3. Mother's Name: ________________________________________________________________________
4. Husband's Name (if Married): ______________________________________________________________
5. Permanent Address: ____________________________________________________________________
________________________________________________________________________________________
Dist. : _________________________________ State: ____________________________________________

Tel. No. / Mobile No.:

PIN No. :

6. Visible identification mark of the Candidate: __________________________________________________

Date

7. Date of Birth

Month

--

--

8. Category (For statistical purpose) [

9. Gender [

]:

Male

Year

]:

GEN

SC

ST

BC-I

BC-II

Female

10. Declaration of the Candidate:

I hereby declare that informations furnished above are correct and all certificates in ORIGINAL are lying with me or
I am able to procure required certificates and will be produced at the time of COUNSELLING. I shall forfeit my candidatures as well as liable for legal action in case any of them is proved to be false at any stage of ADMISSION or
thereafter or if I will not produce relevant required ORIGINAL certificates.
Date:- _____ / ______ / 2015
Place:- _________________

11. Father's / Guardian's / Husband's signature

11

12. Candidate's signature

Jharkhand Combined Entrance

Competitive Examination

Jharkhand Combined Entrance

Competitive Examination

Jharkhand Combined Entrance

Competitive Examination

Boards Copy

Candidates Copy

Challan for B.Sc. Nursing Entrance

Competitive Examination 2015 Application Form

Challan for B.Sc. Nursing Entrance

Competitive Examination 2015 Application Form

Challan for B.Sc. Nursing Entrance

Competitive Examination 2015 Application Form

Cash can be deposited at any Branch of United

Bank of India

Cash can be deposited at any Branch of United

Bank of India

Cash can be deposited at any Branch of United

Bank of India

Account Name
A/c No.
IFSC No.

Account Name
A/c No.
IFSC No.

Banks Copy

Account Name
A/c No.
IFSC No.

C.E.,JCECEBoard A/c - F
1842010000921
UTBI0SCTQ03

Application Form Fee*:Gen/BC I/BC - II

[ ]
ST / SC
[ ]
(Tick [ ] which is applicable)

` 550/` 275/-

* - Last date for submitting the Fee is 24.08.2015.

(To be filled up by the Depositor)

C.E.,JCECEBoard A/c - F
1842010000921
UTBI0SCTQ03

Application Form Fee*:Gen/BC I/BC - II

[ ]
ST / SC
[ ]
(Tick [ ] which is applicable)

` 550/` 275/-

* - Last date for submitting the Fee is 24.08.2015

(To be filled up by the Depositor)

C.E.,JCECEBoard A/c - F
1842010000921
UTBI0SCTQ03

Application Form Fee*:Gen/BC I/BC - II

[ ]
ST / SC
[ ]
(Tick [ ] which is applicable)

` 550/` 275/-

* - Last date for submitting the Fee is 24.08.2015.

(To be filled up by the Depositor)

Candidates Name: ______________________

Candidates Name: ______________________

Candidates Name: ______________________

______________________________________

______________________________________

______________________________________

Category (mention your category): __________

Category (mention your category): __________

Category (mention your category): __________

Fathers Name: _________________________

Fathers Name: _________________________

Fathers Name: _________________________

______________________________________

______________________________________

______________________________________

Date of Birth: ___________________________

Date of Birth: ___________________________

Date of Birth: ___________________________

Mobile No. : ____________________________

Mobile No. : ____________________________

Mobile No. : ____________________________

Transaction ID: __________________________

Transaction ID: __________________________

Transaction ID: __________________________

NFFT / UTR No. (In case of IFSC):

NFFT / UTR No. (In case of IFSC):

NFFT / UTR No. (In case of IFSC):

_________________________

_________________________

_________________________

Deposit Date: ____ / ____ / 2015

Deposit Date: ____ / ____ / 2015

Deposit Date: ____ / ____ / 2015

Signature of
Depositor

Signature of
Depositor

Signature of
Depositor

Authorized Signatory &

Seal

Authorized Signatory &

Seal

Authorized Signatory &

Seal

Instruction for Candidate:- Submit the requisite Application Form fee and collect Board's & Candidate's Copy from Bank. Send the Board's Copy with the Application Form.