GOVERNMENT OF BIHAR

Bihar Combined Entrance Competitive Examination Board

Diploma Certificate Entrance Competitive Examination - 2019
Online Application Form for admission in Various Diploma Courses of Govt. / Pvt. Polytechnic Institutions of
Bihar and Various Para Medical Dental (Matric Level) and Para Medical (Intermediate Level) of Different Govt.
Recognised Hospitals / Institutions for the Session 2019.
Registration No. 4190098633 Please donot send this Hard Copy to BCECE Board
PART- A
1. Course Group Applied for : PE,PMD

2. Name of Candidate : MD TAJ HASAN

3. Father's Name : MD MAHBOOB ALAM

4. Mother's Name : SHAKEELA KHATOON

5. Date of Birth: : 23/ March /2003

6. Gender : MALE

7. Reservation Category : EBC (Extremely Backward Class)

8. Disabled Quota : No

9. Mobile No. : 9570280894

10. Email ID : [email protected]

Note: Please Affix your same photo and put your full signature
in English and Hindi in spaces provided above.
11.Aadhaar Card No. : 480264568710

12. Marks of identification : A CUT MARK ON RIGHT

FOREHEAD
13. Are You Permanent Resident of Bihar? : Yes

14. Residential Eligibility :

15. Do you claim for Economically Weaker Sections (EWS) ? : N/A
16. Are you unable to write due to permanent loss of limbs / suffering from : N/A
Cerebral palsy :
17.(i) Do You Claim SMQ Quota? : No
17.(ii)If Yes, are you Son/Unmarried Daughter of Military Personnel? : N/A
18. Family Annual Income : Less than 8 lakhs
19. District Name of the Institution of Passing/Appearing in Qualifying : BEGUSARAI
Exam:
20. Exam Passed/ Appeared : Passed
21. Percentage of Marks / CGPA Obtained in Qualifying Exam, if Passed : 66.8 %
22.(i) Educational Qualification/ Experience for PPE Course group : N/A
22.(ii) ITI Name : N/A
22.(iii) ITI Course : N/A
22.(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

Registration No:4190098633 Page: 1/2

 22.(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:
23. Have you completed any ANM Course? : N/A
24. Payment Details:
Branch Name Journal No. /Transaction No. Deposit Date Amount (in Rs.)
ONLINE DCE5cdb921cdf811 2019-05-15 09:48:00 Rs. Eight Hundred Fifty
25. Address Details:
A. Permanent Address: B. Correspondence Address:
CHAK HAMID CHAK HAMID
CHAK HAMID CHAK HAMID
BAKHRI BAZAR BAKHRI BAZAR
District: BEGUSARAI District: BEGUSARAI
State: Bihar Pin Code: 848201 State: Bihar Pin Code: 848201
Declaration by the Candidate: I MD TAJ HASAN declare that the informations 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:4190098633 Page: 2/2

 GOVERNMENT OF BIHAR
Bihar Combined Entrance Competitive Examination Board
Diploma Certificate Entrance Competitive Examination - 2019
Online Application Form for admission in Various Diploma Courses of Govt. / Pvt. Polytechnic Institutions of
Bihar and Various Para Medical Dental (Matric Level) and Para Medical (Intermediate Level) of Different Govt.
Recognised Hospitals / Institutions for the Session 2019.
Registration No. 4190098633 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-2019 Counselling) DCECE-2019 Counselling) DCECE-2019

1. Course Group Applied for : PE,PMD

2. Name of Candidate : MD TAJ HASAN

3. Father's Name : MD MAHBOOB ALAM

4. Mother's Name : SHAKEELA KHATOON

5. Date of Birth: : 23/ March /2003

6. Gender : MALE

7. Reservation Category : EBC (Extremely Backward Class)

8. Disabled Quota : No

9. Mobile No. : 9570280894

Note: Please Affix your same photo and put your full signature
10. Email ID : [email protected] in English and Hindi in spaces provided above.

11. Aadhaar Card No. : 480264568710

12. Marks of identification : A CUT MARK ON RIGHT

FOREHEAD
13. Are You Permanent Resident of Bihar? : Yes
14. Residential Eligibility
:
15. Do you claim for Economically Weaker Sections (EWS) ? : N/A
16. Are you unable to write due to permanent loss of limbs / suffering from : N/A
Cerebral palsy :
17. (i) Do You Claim SMQ Quota? : No
17. (ii) If Yes, are you Son/Unmarried Daughter of Military Personnel? : N/A
18. Family Annual Income : Less than 8 lakhs
19. District Name of the Institution of Passing/Appearing in Qualifying Exam: : BEGUSARAI
20. Exam Passed/ Appeared : Passed

Registration No:4190098633 Page: 1/4

 21. Percentage of Marks / CGPA Obtained in Qualifying Exam, if Passed : 66.8 %
22.(i) Educational Qualification/ Experience for PPE Course group : N/A
22.(ii) ITI Name : N/A
22.(iii) ITI Course : N/A
22.(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
22.(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:
23. Have you completed any ANM Course? : N/A

24. Address Details:

A. Permanent Address: B. Correspondence Address:
CHAK HAMID CHAK HAMID
CHAK HAMID CHAK HAMID
BAKHRI BAZAR BAKHRI BAZAR
District: BEGUSARAI District: BEGUSARAI
State: Bihar Pin Code: 848201 State: Bihar Pin Code: 848201
25. Educational Qualification:
School/College Passing
Level Subject Board/University Name Passing Status Percentage/CGPA
Name Year
UTKRAMIT
MADHYAMIK
SCHOOL Bihar School Examination
Secondary/Standard X All Subject Passed 2019 66.80
CHAKHAMID Board
NADAIL
BEGUSARAI
(10+2) / I.Sc./ Equivalent N/A N/A N/A N/A N/A N/A

26.(A) Declaration of Candidate:

( )

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

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

Registration No:4190098633 Page: 2/4

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

MD TAJ HASAN

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

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

27. List of Enclosure:

1. 2.

3. 4.

5. 6.

7. 8.

Registration No:4190098633 Page: 3/4

 28.
(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) ..........................

29.
(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)-2019 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)-2019 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)-2019 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:4190098633 Page: 4/4