ANNEXURE III

GOVERNMENT OF NCT OF DELHI

AUTOMOTIVE MECHATRONICS RESEARCH CENTRE
G B Pant DSEU Okhla-III Campus
OKHLA PHASE III, NEW DELHI-110020
Email: [email protected] Website: http://www.gbpit.ac.in

Phone: 011-2682662
ADVANCE DIPLOMA IN AUTOMOTIVE MECHATRONICS (ADAM)
Application Form 2023

1. PERSONAL DETAILS:
a) Name of Candidate
(in Block Letter) Affix a Recent
b) Father’s / Guardian’s
Photograph
Name & Occupation
c) Date of Birth d) Gender

e) Nationality

f) Permanent Address

PIN:
Important Instructions:
g) Address for (i) Candidates are advised
Correspondence to read information
bulletin before filling up
the application form.
PIN:
(ii) No column should be
h) Mobile No. i) Phone (R) left blank. If any column
is not applicable, write
j) e-mail N.A.

k) Category SC ST OBC Gen (iii)Application form

(please tick any one) should be clearly, legibly
l) Examination Centre (1) filled with black ball
(in the order of point pen / neatly typed
Preference) (2)

2. QUALIFYING EXAMINATION DETAILS:

Qualification Discipline Board / University CGPA / Percentage Year of
of Marks Passing
B.E / B.Tech

Diploma

XII

X
 3. DETAILS OF WORK EXPERIENCE:
Name and address of Employer / Organization Post Held Duration

4. FEE DETAILS:
a) Name of Bank
b) Reference No. / Transaction ID c) Date
Note: Proof of Fee Paid to be scanned and sent along with this application form.

5. Govt. of India ID card Number Particulars of ID ( Select any one)

issued ID card Passport / PAN / Aadhar / Driving License
/ EPIC
Details:
Note: 1. Candidate is supposed to carry the same ID card to the examination centre on the day of exam
2. Candidate should send a single clear PDF file containing (a). Duly filled & signed application form (b). Proof of examination
fee paid (online) & (c). The same valid photo identity card as mentioned at column 5 of this application form.

Declaration:
1. I hereby certify that the information provided by me in application form is correct to the best of
my knowledge and I have not concealed any information in any manner.
2. I certify that I am not involved in any illegal activity and no criminal case is pending against me in
any court of law.
3. If ineligibility of the candidate is detected at any stage, before or after the
examination/declaration of results, or during any stage of the course, his/her
candidature/admission will be cancelled without any notice. Disciplinary action will be taken
against him/her and entire fee will also be forfeited.
I hereby declare that I have read and fully understood all the conditions above and freely agree
to abide by them.

Date:

Station: Signature of the Candidate

(In Black ball point pen)

FOR OFFICE USE ONLY

(DO NOT WRITE / MAKE ANY STARY MARKS HERE)
Registration No.

Date of receipt

Admission Granted YES/NO

Fee Receipt No.

Remarks, if any