Transcript Download ESDM Form - NIELIT, Gorakhpur Centre

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National Institute of Electronics and Information Technology, Gorakhpur
M.M.M.U.T. Campus, Gorakhpur - 273010, U.P.
1 Application Form For ESDM Courses
पा यक्रम का नाम
Course Name
:
2 पा यक्रम तर
: Course level (PLACE X)
3 िव याथीर् का नाम
Name of the Candidate
:
िपता का नाम
:
4 ______________________________________________
___
L1 L2 L3 L4 L5 __________________________________________
_ PASTE
RECENT
PASPORT SIZE
PHOTOGRAPH __________________________________________
_ Father’s Name
6 ज म ितिथ/Date of Birth
7 पत्र य हार का पता
____________________________________________________________
Correspondence Address
___ :
___________ आधार संख्या/पैन संख्या Aadhar No/Pan No :______________________ ______________________Pin Code
_________________________________________ 8 थाई पता
_______________________Pin
Permanent Address
9 Code________________________________________
ई-मेल /E-mail
____________________________________________________________
___ 10 मोबाइल संख्या /Mobile No
11 वगर्(सामा य/अनस
ु िू चत जाती/अनस
ु िू चत जनजाित/गरीबी रे खा के नीचे)
12 13 S.No
1
_______________________ Alternate Mobile No(Parents)
_______________________ Category(Gen/SC/ST/EWS*)__________________________________________________________________________________
*Economically Weaker Section धमर्/ReligionReligion________________________________________________________________________________________
_______ शैिक्षक योग्यता/ Educational Qualification
Exam Passed
8th Pass
ITI
2
3 Years
DIPLOMA
Matriculation
3
Intermediate
4
Graduation
5
Post
year of Boa
Passing rd/
Uni
rve
sty
Subject
Percentage of
Marks Division
Graduation
6
Others
घोषणा DECLARATION I hereby to delare that all the entries in this form are true to best of my knowledge and belief. I also undertake to comply : 1. To maintain 80% attendence in theory and practical classes. 2. To maintain ateast 50 marks in examination . 3. to follow disciplene of NIELIT ,Gorakhpur. 4. Not to cLAIM for refund of fees in case i fail in the NIELIT Exam . थान/Place: _________________ िदनांक/Date: _________________ (आवेदक का ह ताक्षर) (Signature of the Candidate ) संलग्नक के अनस
ु ार [] का clclaclagclagaclagayclagayeिच ह लगाये | Checklist for Enclosure Tick [ ] 1. 8th pass Marksheet and Certificate [ ] 2.
ITI Marksheet and Certificate [ ] 3.
3 years Diploma Marksheet and Certificates [ ] 4.
High School Marksheet and Certificate [
5.
Intermediate Marksheet and Certificate [ ] 6.
Graduation Marksheet and Certificate [ ] 7.
Post Graduation Marksheet and Certificate [
8.
Caste Certificate [ ] 9.
Incum Certificate [
10. Address Proof [
] ] ] ] For Office Use Only
Fees detail: Amount
Challan
Date
R. No.
____________ ____________ _____________
_____________ Admitted
Yes
No Course Coordinator