Government of West Bengal
Backward Classes Welfare and Tribal Development Department
Pre-Examination Training – JEE/WBJEE / NEET - 2025
APPLICATION FORM
TYPE CLASSROOM COACHING AND TEST MEDIUM ENGLISH / BENGALI
EXAM JEE (Engg) NEET (Med) YEAR 2025 One copy
photo is to
CENTRE be affixed
FILL IN THE FORM IN BLOCK LETTERS
PARTICULARS OF STUDENT
1. Name : …………………………………....………………………………….................................. Date of Birth .......... / ......... /................
(DD /MM /YYYY)
2. Sex : Male Female 3. Community : SC ST
4. Correspondence Address : ..............................................................................................................…………..……...........
.....................…………….......................................... PIN : ……………….………….. Phone : ..........….........……….….....
5. Email id : .................................…….………...........................................................................…………................................
6. Permanent Address : .................................…….………...........................................................................…………..............
.................................................................................. PIN : ……………...................... Guardian’s Ph : …….……........…..
7. Examination(s) Passed :
Exam Name Year Marks % of Marks Name of the Institution
X
8. Present Institution : ………………………………………………………………....…………………..……............................................... Class : ..........................…..
PARTICULARS OF PARENT / GUARDIAN
1. Father’s Name : ………….………………………………………………………………………..……. Occupation : ....……………………….…
2. Mother’s Name : ...………………….…………………………………….……………………….... Occupation : ....…………….…….….…
3. Guardian’s Name : .………………….……………………………………………………...…….... Occupation : ....…………….…….….…
Office/Business Name : .…………….…………………….………………..………………………
Address : .......................................................................................................................................................................
4. Annual Family Income : ..............................................................................................................................................
Student Bank Account Details : .
Bank Name : ………………………………………………………………….. A/C No. : …….………………………………………………….
Branch Name : ………………………………………………………………. IFSC Code : …………………………………………………….
AADHAR No. : ………………………………………………………………..
I do solemnly declare that all the particulars given above are true. I shall abide by the guidelines of the
Backward Classes Welfare and Tribal Development Department, Government of West Bengal.
Date : …………………………................... ………….……………………………………. ……………………………….…………..…………………….
(DD / MM / YYYY) (Student’s Signature) (Parent’s / Guardian’s Signature)
To be enclosed : (a) One copy passport size photo,
(MANDATORY) (b) Copy of Mark Sheet(s) of class – X Standard,
(c) Copy of SC/ST Certificate,
(d) Copy of AADHAR Card,
(e) Family Income declaration,
(f) copy of Bank passbook front page
Declaration on Family Income by Parent / Guardian of the applicant
I …………............................................................ the parent / guardian of …..............................................
residing at ................................................................................................................................................
................................................................................................................................. hereby declare that
I belong to SC/ST Community and my annual family income from all sources is
Rs........................................... (in figures) Rupees ..................................................................................
.................................................... only (in words).
I also declare that, in any stage, the information given by me if proved to be false / not true, benefit
of the scheme may be withdrawn and legal action as deemed fit by the authority may be taken
against me or my ward.
_____________ _____________________________
Date Signature of Parent / Guardian
LIST OF TRAINING CENTRES
No. of No. of
Sl District Centre Sl District Centre
Centre Centre
1 North 24 PGS Bagdah 26 Cooch Behar Cooch Behar Town
2 North 24 PGS Barasat 27 Cooch Behar 3 Dinhata
4
3 North 24 PGS Barrackpore 28 Cooch Behar Mathabhanga
4 North 24 PGS Bashirhat 29 Dakshin Dinajpur 1 Balurghat Town
5 South 24 PGS Baruipur 30 Darjeeling 1 Siliguri Town
6 South 24 PGS Diamond Harbour 31 Darjeeling 1 Darjeeling
4
7 South 24 PGS Canning 32 Hooghly Tarakeshwar
8 South 24 PGS Namkhana 33 Hooghly 3 Arambagh
9 Bankura Bankura Town 34 Hooghly Bandel
10 Bankura 3 Khatra 35 Jalpaiguri Jalpaiguri Town
11 Bankura Bishnupur 36 Jalpaiguri 3 Malbazar
12 Howrah 1 Bagnan 37 Jalpaiguri Dhupguri
13 Jhargram 1 Jhargram 38 Kalimpong 1 Kalimpong
14 Paschim Bardhaman 1 Durgapur Town 39 Malda Malda Town
2
15 Paschim Medinipur Medinipur Town 40 Malda Chanchal
16 Paschim Medinipur 3 Kharagpur 41 Nadia Krishnagar
17 Paschim Medinipur Sabang 42 Nadia 3 Kalyani
18 Purba Medinipur 1 Contai 43 Nadia Ranaghat
19 Purulia Manbazar 44 Purba Bardhaman Bardhaman
2
20 Purulia Purulia Town 45 Purba Bardhaman 3 Ambika Kalna
21 Alipurduar Alipurduar 46 Purba Bardhaman Katwa
2
22 Alipurduar Madarihat 47 Uttar Dinajpur Raiganj
2
23 Birbhum Suri 48 Uttar Dinajpur Islampur
2
24 Birbhum Rampurhat 49 Murshidabad Jangipur
2
25 Kolkata 1 Kolkata 50 Murshidabad Berhampore