ANNEXURE V: APPLICATION FORM FOR GCET 2016

FORM (A)
Recent
Roll No. Photograph
(Not to be filled by candidate)
(Paste Here)
INSTRUCTIONS:
i) Candidates are advised to read instructions overleaf carefully before filling the form.
ii) Applicant must fill the form in his/her own handwriting, after downloading &
printing the FORM A from the website, on good quality A4 Size bond paper
and submit the same at the notified locations (as per Centre opted), on specified dates,
along with self attested copies of required documents.
NAME: (In CAPITAL LETTERS as it appears in SSCE certificate)

DATE OF BIRTH: (as in SSCE certificate) - -

PLACE OF BIRTH:________________________ GENDER: Male Female

(Tick the appropriate box)

ADDRESS: House No.__________________ Street Name/Area__________________

_________________________________________________________________________
Village/Town/City_______________________ Pin Code _____________State___________
PHONE NO

MOBILE
ACADEMIC DETAILS:
Exam Board Exam (Month/Year) Exam Seat No.
XII Science
GCET Subjects and Centre: Encircle appropriate boxes for the subjects opted, crossing out subjects not opted (X)
GCET SUBJECT CODE PY CH MA BY Payment
GCET CENTRE CODE Centre name: - Details:

DD No. Bank Name: Dated:

DECLARATION
I, _____________________________________ state that I have read and accepted the provisions of the Prospectus and GCET Rules,
and have enclosed the self-attested copies of all the certificates required and submitted the application complete in all respects. In the event
of my application found to be incomplete and hence rejected by the admitting authority, I shall be held responsible for the same.
I, hereby declare that the particulars furnished above are true, complete and correct to the best of my knowledge and belief. I am fully
aware that in the event of any information being false or incorrect and detected before or after the admission, appropriate action as deemed fit
by the Competent Authority can be taken against me.

PLACE: __________________ DATE:____________________

(Signature of the Applicant) (Name of Applicant)

(Signature of Parent/Guardian) (Name of Parent/Guardian)

DIRECTORATE OF TECHNICAL EDUCATION, ALTO-PORVORIM, GOA, 403521

INSTRUCTIONS TO BE FOLLOWED WHEN FILLING UP THE APPLICATION FORM

1. PHOTOGRAPH affixed on the form should be a recent one i.e. taken not earlier than 3 months prior to the date
of application. 2 additional identical passport size photographs are to be enclosed with this form.
2. Write your NAME in CAPITAL LETTERS and DATE OF BIRTH as it appears in your Secondary School Certificate
Examination (SSCE) certificate.
3.ADDRESS must be complete, including the postal code.
4.TELEPHONE NUMBER must be given with area code in brackets.
5.SUBJECT CODE: Encircle codes of subjects you intend to attempt

CODE SUBJECT
PY Physics
CH Chemistry
MA Mathematics
BY Biology
6. CENTRE CODE: Choose your centre by writing the centre code and name

S.No. Centre Code Address

1 Tiswadi 10 Dhempe Higher Secondary School of Arts & Science
Cujira(Bambolim)
2 Panaji 11 Goa College of Pharmacy
3 Verna 12 Fr. Agnel Multipurpose Higher Secondary School
4 Navelim 13 Rosary College / Higher Secondary of Arts & Commerce
5 Vasco 14 Deep Vihar High School
6 Mapusa 15 Purushottam Walawalkar Higher Secondary School
7 Ponda-1 16 A. J. De Almeida High School
8 Ponda-Farmagudi 17 G. V. M’s. Smt. N. J. Aguiar Higher Secondary School
9 Bicholim 18 Narayan Zantye College of Commerce
10 Curchorem 19 Smt. Chandrabhaga T. Naik Higher Secondary School
11 Porvorim 20 Vidya Prabodhini Higher Secondary School
12 Assagao 21 DM’s PVS Sarojini M. Kushe Higher Secondary School
13 Sanquelim 22 Govt. Higher Secondary School
14 Cuncolim 23 Maria Bambina Higher Secondary School
15 Dharbandora 24 BBSS Vishweshwar Shankar Laad Higher Secondary School
* Additional Centres may be notified as per requirement.
7. Self attested photo copies of the following CERTIFICATES to be enclosed:
a) SSCE Passing Certificate.
b) Std XIIth passing certificate or HSSC Examination Hall Ticket.
8.This Form should be accompanied by Demand draft for Rs. 1500/-payable at Panaji, in favour of “Director
of Technical Education” drawn on any Scheduled Bank, or any other approved form of remittance, as may
be duly notified. Dates for submitting completed forms: 28th March, 2016 to 2ndApril, 2016.

DIRECTORATE OF TECHNICAL EDUCATION, ALTO-PORVORIM, GOA, 403521