Note :

1. Fill in all particulars in Block Letters.

2. Use a Tick [/] Mark whenever needed.

Name of the course :

From :                                                                                To :

__________________________________________________________________________

1.  NAME :    

2. DESIGNATION:

3. AREA OF WORK :

4. OFFICE ADDRESS :

CITY :  

  PINCODE:

5. CATEGORY [ Pl. Tick mark]:                SC / ST /  OTHERS  

6. QUALIFICATION[ Pl. Tick mark] :        DIP. ENGG /    DEGREE ENGG.  /    NTC/NAC

7. BRANCH (ENGG. TRADE):

8. SPONSORED [ Pl. Tick mark] :            YES /     NO

9. ORGN. CODE ( if sponsored ) :       

• U for Public Sector Undertakings - Large & Medium
• P for Private Sector - Large & Medium
• S for Small Scale Industries
• D for Govt. Deptt.  -  Defence, Railways etc.

10. COURSE FEE WILL BE PAID [ Pl. Tick mark]:        BY ORG. / BY CANDIDATE

11.CONTACT TELEPHONE NO. :

12. SPONSORING AUTHORITY :

        DESIGNATION :

DATE :                                                                                            SIGNATURE OF THE CANDIDATE

__________________________________________________________________________

(For Office use only)

Registration No.

Dealing Asst.                                                                                                                        Director