Long Term Courses Application form for 2015-16
Transcription
Long Term Courses Application form for 2015-16
No: National Institute of Electronics and Information Technology Imphal APPLICATION FORM FOR ADMISSION TO LONG TERM COURSE (Please refer to prospectus for instructions to fill up the form) 1.Course applied for : DECE/DCSE/PGDCA/ O-level/ A-level/CHM-O/CHM-A/BCA/MCA/MAT-O (a). If applied for more than one course in separate forms, give name of preferred course. (Write Course Name) Your passport size Photograph attested by a Gazetted Officer. 2. Name (in block letters): 3. Aadhaar No.: 4. Father’s Name (in block letters): 5. Mother’s Name (in block letters): 6. Guardian’s Name (if parents are not alive): 7. Address for correspondence: Pin Pin - Phone : 8. Permanent address: Mobile : Pin Phone : Mobile : 9. Gender: Male Female 0 10. Date of birth: Day 11. Category: SC Month ST OBC Year P/H Minority Gen Others 12. Religion 13. State of domicile M.R. No…………… For Office use only Date…………. Category ……………. Authorized Signatory……………………. 14. Examination Passed/Appeared: Board/Univ. Examination passed/appeared Year of passing/ appearing % Marks (if applicable) Math Science Overall Percentage Class/ Division Comp. Sc I hereby declare that the above information is true to the best of my knowledge and belief. I also undertake that if I am selected and admitted, I shall abide by the rules and regulations of NIELIT, Imphal as conveyed from time to time, failing which I may be expelled from the Centre. Place: Date: Signature of the Applicant 15. List of enclosures: a) Copy of Aadhaar Card b) Age proof certificate c) Caste/ Tribe/OBC/ P/H certificate, etc. (if applicable) d) Qualifying certificates & mark sheets. e) ……………………………………………………. Signature of Parent/Guardian NIELIT IMPHAL No. ADMIT CARD Name of the course: DECE/DCSE/PGDCA/ O-level/ A-level/CHM-O/CHM-A/BCA/MCA/MAT-O 1. (Write Course Name) Your passport size Photograph attested by a Gazetted Officer. (a). If applied for more than one course in separate forms, give name of preferred course. 2. Name: (in block letters as in the application form) Signature of the Candidate do not write anything below this line. ……………………………………………………………………………………………………………………. (Sl. No. 3 to 5 to be filled in by office) 3. Roll No. 4. Venue for entrance test : ……………………………………………………………………………………… : ... …………………………………………………………………………………… 5. Date of entrance test : ……………………………………………………………………………………… 6. Reporting time : 9. 30 a.m. 7. Test duration : 10 a.m. to 12 noon (Co-ordinator of Examination)