GOVERNMENT OF BIHAR

Bihar Combined Entrance Competitive Examination Board

Online Application Form for Bihar Combined Entrance Competitive Examination (BCECE) - 2021
for admission to First Year Degree Courses
Registration No. 2210028057 Please donot send this Hard Copy to BCECE Board
PART- A
1. Course Group Applied For : PCB

2. Name of Candidate : ALFEYA NIZAMI

3. Father's Name : MD AHTESHAM MALLICK

4. Mother's Name : SHAGUFTA PARVEEN

5. Date of Birth: : 30/ November /2002

6. Gender : Female

7: Reservation Category : BC (Backward Class)

8. Disabled Quota : No

9. Mobile No. : 906****287 Note: Please Affix your same photo and put your full
signature in English and Hindi in spaces provided above.

10. Aadhaar Card No : 540*********781

11. Email ID : [email protected]

12. Marks of identification : A MOLE ON FACE
13. Are You Permanent Resident of Bihar? : Yes
14. Residential Eligibility
:
15. Are you unable to write due to permanent loss of limbs / suffering from : N/A
Cerebral palsy :
16. District Name of the Institute of passing/appearing at I.Sc or equivalent : NAWADA
17. Family Annual Income : N/A
18. Do you claim for Economically Weaker Sections (EWS) ? : N/A
19. Do you claim SMQ Quota : No
20. Are you Son/Unmarried Daughter of Military Personnel? : N/A
21. Percentage of marks obtained in qualifying examination, if Passed:
( Physics+ Chemistry+ Biology): 59.00% (English): 78.00%
22. Payment Details:

Payment Mode Journal No. / Transaction No. Deposit Date Amount (in Rs.)
ONLINE BCE6134827d8d653 2021-09-05 14:12:54 Rs. One Thousand
23. Address Details:
A. Permanent Address: B. Correspondence Address:
MOHALLA - RAZA NAGAR BHADAUNI MOHALLA - RAZA NAGAR BHADAUNI
BHADAUNI BHADAUNI
NAWADA NAWADA
District: NAWADA District: NAWADA
State: Bihar Pin Code: 805110 State: Bihar Pin Code: 805110
Declaration by the Candidate: I ALFEYA NIZAMI 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)

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 GOVERNMENT OF BIHAR
Bihar Combined Entrance Competitive Examination Board
Online Application Form for Bihar Combined Entrance Competitive Examination (BCECE) - 2021
for admission to First Year Degree Courses
Registration No. 2210028057 Please donot send this Hard Copy to BCECE Board
PART- B
(For office use only)
Select for admission(First Counseling) Select for admission(Second Counseling) Select 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
Counseling) BCECE-2021 Counseling) BCECE-2021 Counseling) BCECE-2021
Date: Date: Date:

1. Course Group Applied For : PCB

2. Name of Candidate : ALFEYA NIZAMI

3. Father's Name : MD AHTESHAM MALLICK

4. Mother's Name : SHAGUFTA PARVEEN

5. Date of Birth: : 30/ November /2002

6. Gender : Female

7. Reservation Category : BC (Backward Class)

8. Disable Quota : No

24. Mobile No. : 906****287

Note: Please Affix your same photo and put your full signature
25. Aadhaar Card No : 540*********781 in English and Hindi in spaces provided above.

9. Email ID : [email protected]

10. Marks of identification : A MOLE ON FACE

11. Are You Permanent Resident of Bihar? : Yes
12. Residential Eligibility
:
13. Are you unable to write due to permanent loss of limbs / suffering from : N/A
Cerebral palsy :
14. District Name of the Institute of passing/appearing at I.Sc or equivalent : NAWADA
15. Family Annual Income : N/A
16. Do you claim for Economically Weaker Sections (EWS) ? : N/A
17. Do you claim SMQ Quota : No
18. Are you Son/Unmarried Daughter of Military Personnel? : N/A
19. Percentage of marks obtained in qualifying examination, if Passed:
( Physics+ Chemistry+ Biology): 59.00% (English): 78.00%
20. Address Details:

Registration No:2210028057 Printed On: 20-12-2021 16:35:20 Page: 1/3

 A. Permanent Address: B. Correspondence Address:
MOHALLA - RAZA NAGAR BHADAUNI MOHALLA - RAZA NAGAR BHADAUNI
BHADAUNI BHADAUNI
NAWADA NAWADA
District: NAWADA District: NAWADA
State: Bihar Pin Code: 805110 State: Bihar Pin Code: 805110
21. Educational Qualification:

Level School/College Name Board/ University Name Passing Status Passing Year
Secondary/Standard ST JOSEPH SCHOOL PO DIST Central Board of Secondary
Passed 2019
X NAWADA BIHAR Education
S S AGRAWAL MAHILA
I.S.C./XII (10+2) Bihar School Examination Board Passed 2021
COLLEGE NAWADAH
(Submit Marksheet of Matriculation and I.Sc. if passed)

22. Marks Details:

% of Marks % of Marks % of Marks
Subject in I.Sc/10+2 % of Marks obtained in
S.N. Marks Obtained Total Marks obtained in obtained in obtained in
Exam CBA/PCA/MBA/MCA
English PCM PCB
1 English 78 100
2 Physics 56 100
78.00% N/A 59.00% N/A
3 Chemistry 58 100
4 Biology 63 100

23. Declaration of the Candidate:

I, ALFEYA NIZAMI Son/ Daughter of MD AHTESHAM MALLICK hereby solemnly and sincerely affirm the statements made and information
furnished above by me and in the enclosures hereby submitted by me are true and correct. I have not kept my information secret. If, however, it
is found that any information furnished therein is fraudulent, incorrect or untrue in materials/particulars, I realize that I am liable criminal
prosecution and agree to forego my seat in the college and further that the selection and admission to this course is liable to be canceled. I
agree to abide by the rules and regulations governing this Examination and as contained in the prospectus of BCECE - 2021 .

Repeat below in your handwriting (not in capital letters) the above mentioned Declaration and put your signature in English and Hindi
at the specified spaces as signed in Part A of the Online Application Form. If you fail to do so, your Candidature shall be rejected:

...............................................................................................................................................................................................................................

...............................................................................................................................................................................................................................

...............................................................................................................................................................................................................................

...............................................................................................................................................................................................................................

...............................................................................................................................................................................................................................

...............................................................................................................................................................................................................................

Place: Full Signature (in Hindi) ..................................

Date: Full Signature (in English) ..................................

Counter Signature of Father/Mother/Husband/Guardian ..................................

24. List of Enclosure:

1.
2.
3.
4.
5.
6.
7.
8.

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 25.
(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)

26.
(FOR OFFICE USE OF THE CONCERNED INSTITUTE ON THE BASIS OF FIRST COUNSELLING)

Roll No. ........................................ Reservation Category .................................... Merit Serial ............... of BCECE- 2021 in the

First Year of ........... Branch/Course 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 BCECE- 2021 in the First

Year of .......... Branch/Course of the Institute ................................................ as He/She fulfilled all the requirements of being

admitted.

SEAL OF THE INSTITUTE SIGNATURE OF THE

PRINCIPAL/SUPERINTENDENT

(FOR OFFICE USE OF THE CONCERNED INSTITUTE ON THE BASIS OF THIRD COUNSELLING)

Roll No........................................ Reservation Category .................................. Merit Serial ............... of BCECE- 2021 in the First

Year of ............ Branch/Course of the Institute ................................................ as He/She fulfilled all the requirements of being

admitted.

SEAL OF THE INSTITUTE SIGNATURE OF THE

PRINCIPAL/SUPERINTENDENT

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