Dr. Ambedkar Competitive Examination Center (ACEC) - yashada

APPLICATION NO:
Dr. Ambedkar Competitive Examination Center
(ACEC)
www.yashada.org/acec
APPLICATION FORM FOR MAIN EXAMINATION –2012
(Admission)
1. Full Name of the Candidate: (In Block letters starting with surname)
Shri/Smt. --------------------------------------------------------------------------------------------
Write in Marathi also: --------------------------------------------------------------------------
2. Full Postal / Permanent Address with :
Pin code
Tel No.(with STD code No.)
3. Local Address and Mobile No. : :
4. Name of Local Guardian with Full address:
(With Mobile number of Guardian)
5. Mobile number & Email Address :
of Candidate:
6. Are you domicile of Maharashtra : YES/NO
7. UPSC-Prelims-2012 Roll Number : __________________________________
8. Please mention your Category
‣ Gender : _______________________________
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‣ Whether Physically Disabled or Not : ___________________________
If Yes, mention the type of Disability : ___________________________
___________________________
Tick mark “√ “ for the category applicable: _________________________________
General SC ST VJ(A) NT(B)
NT (C) NT(D) SBC OBC
Sikh Muslim Christian Buddhist Jain
8. Annual Income of Family :
9. (a) Date of Birth in figures : / / 19
in words :
(b) Age as on 1 st Aug. 2012: Years Months Days
10. Educational Qualification:
Give particulars of all examination passed, commencing with S.S.C. Examination
Examination
Passed
Name of school /
college with
Board
/University
Year of
passing
Optional subjects Class/
Division
Percentage
Of marks
address
/Grade
1 2 3 4 5 6 7
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11. Optional Subjects for Main Examination-2011: (1) ---------------------------------------
(2) --------------------------------------
12. Have you enrolled for any other regular Course YES/NO
If yes: Details:------------------------------------------------------------------------------------
13. Were you a student of SIAC, Mumbai or its any regional Centers or any govt.
Sponsored institute who is indulged in providing training for Civil Service Exams.
Details with Year: ---------------------------------------------------------------------------
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14. Whether employed /self employed/ unemployed
If employed details of employment:
Details: -----------------------------------------------------------------------------------------
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15. Were you a student of ACEC, YASHADA, Pune Institute earlier: YES/NO
If yes mention year -
16. Are you selected by UPSC/rank holder
(Tick √ mark in the appropriate place/places.)
Course Prelims Mains Interview
Tick √
Year
If yes: Details:- Post --------------------------------------------------------------
Batch ---------------------------------------------------------------
17. If you were appeared for UPSC- Main, earlier, mention all attempts:
Details: --------------------------------------------------------------------------------------
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18. If you were appeared for UPSC- Interview, earlier, mention all attempts:
Details: --------------------------------------------------------------------------------------
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Note: Original copies of following must be provided for verification with the application form.
Attested Photocopies of all following Documents should be attached with application Form.
Candidate should tick mark against all documents enclosed in Table below.
1.Certificates of Educational Qualifications, 1st Degree/ PG Certificate
2 Date of Birth Certificate / SSC Certificate
3 Caste Certificate, Caste Validation Certificate
4. School Leaving Certificate
5. Evidence of belonging Minority group
6. Domicile Certificate /Nationality Certificate
7. Latest Creamy Layer Certificate (candidates whom it is applicable)
8.Photo Identity Proof
(e.g Election Card, Driving License, Pan card etc.)
9. Four recent color Photographs (Passport size)
10. Character Certificate (from Principal /HoD/ MLA or any Govt.gazzeted
Officer )
11. Valid Residential Proof (Ration Card, Electricity Bill, Election Card/Voter
ID, Tel. Bill)
12. Rs. 2000/‐ (Rs. Two Thousand only) as refundable Deposit.
Above given information is “ True and Correct” to the best of my knowledge and belief, Any kind of discrepancy found, I
will be fully responsible for disciplinary action , as per rules and regulation of ACEC, YASHADA.
Date
Signature of candidate
Place
Name:
=====================================================================
FOR OFFICE USE ONLY
Category Gender Minority
students
Rank
Holder
Fresh
Candidate
Exstuden
t of
ACEC
Already
Mains
Given
and No.
of
attempts
Marks of an
ACEC
Entrance
Test
Remarks
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