Short Term & ESDM Courses Application form for 2015-16

National Institute of Electronics and Information
Technology (NIELIT), Imphal
No:
(Formerly , DOEACC Centre Imphal)
APPLICATION FORM FOR ADMISSION TO SHORT TERM & ESDM COURSES
Course interested in :……………………………………………………………….
Course Fee
:…………………………………..
Your passport
size
Photograph
attested by a
Gazetted
Officer.
1. Aadhaar No:
(Tick and write the no.(s))
2. Name (in block letters):
3. Father’s Name (in block letters):
4. Guardian’s Name (if parents are not alive):
5. Address for correspondence:
Pin
Mobile :
6. Gender:
Male
Female
7. Date of birth:
Day
Month
8. Category:
SC
ST
OBC
Year
P/H
Minority
Gen
Others
9. Highest Examination Passed/Appeared: ………………………………………………………………
Undertaking
(a) My short – term course certificate will not be issued to me if, I,
i)
attend less than 80 p.c of the classes, or
ii)
do not pass the exam conducted by NIELIT concerning the short – term course
(b) My Caution money deposit …………. (Rupees …………………………..) will not be refunded to me if I attend less than
80 % of the classes.
Place:………………………………………
Date:………………………………………
Signature of the applicant
For Office use only
M.R./DD/Cheque No………………….……… Date………………………. Amount ……………………….
Category …………….
Authorized Signatory…………………………………………….