certificate examination form

5/23/2015 CertificateExaminationForm

http://student.nielit.in/CAND/CertificatePreview.aspx?qs=tOuoL91aBzHm/BNZHzARqw== 1/1

NationalInstituteofElectronicsandInformationTechnologyDepartmentofElectronicsandInformationTechnology,MinistryofCommunicationsandInformationTechnology,GovernmentofIndia

OnlineExaminationApplicationForm:CourseonComputerConcepts(CCC)

ApplicationNumber ApplicationDate&Time ForOfficeUseOnly

DLCCC0018925 23May201510:43:15PM

DemandNoteNumber 612698

DemandNoteDate 23May2015

1.ExaminationDetails/ AppliedforExamination/ CCCJuly,2015(EveryMonthExamCycle)AppliedAs/ DirectExaminationCenter1/1 NDLDelhi ExaminationCenter2/2 LNWLucknowAppearedinPreviousCCCExam/CCC No

2.Applicant'sPersonalDetails/Applicant'sfullname/ Mr.AbhishekVermaFather'sName/ Mr.SurajPrasadVermaMother'sName/ Mrs.BindeshwariVermaGender/ Male Category/ OtherBackwardClass/DateofBirth/(dd/mm/yyyy) 10Jul1992 Occupation/ Others/AadharCardNumber/ 434769920840

3.ContactDetails/PhonewithSTDcode/ MobileNumber/ 9599690476EmailAddress/ abhishek.verma066@gmail.com

4.AddressDetails/AddressLine1/1 56VillMajhigwanPostBanniAddressLine2/2 KhrailaThanaManpurAddressLine3/3 TehBiswanCityName/ Sitapur District/ SitapurState/ UttarPradesh PinCode/ 261145

5.Educational/QualificationDetails//HighestEducationalQualification/ GraduationOrHigherYearofPassing/ 2014

6.Declaration/

IsonofSmtBindeshwariVermaandShriSurajPrasadVermaherebydeclare,that,theparticularssubmittedbymeintheonlineexaminationapplicationformofCCCaretruetothebestofmyknowledgeandbelief.IagreetoabidebytherulesandregulationsofNIELITandalsotothedecisionofNIELITregardingmyadmissionfortheexamination.Ihavenotedthat,NIELIThastherighttowithholdmyresultevenaftermyappearingintheexaminationinadditiontoanyotheractionasmaybedeemedfitintheeventofanyofthestatements/particularsmadeabovebeingfoundincorrect.Ihavenotedthat,Imightberequiredtoappearintheexaminationatanyotherexaminationcentrenotspecifiedunderexaminationcentrechoicecolumn(1).Ifurtherunderstandthat,intheeventofnonconduction/nonevaluationofmyexaminationduetoanyreasonwhatsoever,IwillnotheldNIELITresponsibleforanydamages.,BindeshwariVermaSurajPrasadVerma.............../,(1), / , .....7.PaymentDetailFeeDetails: ExamFee:360.00[ThreeHundredSixtyRupeesOnly]PaymentMode: NotPaid PaymentTransactionNo./ NotPaidLastdateoffeepaymentandsubmissionofexaminationformis31May2015afterthisdateyouwillnotbeallowedtosubmittheexaminationform.PleasepayyourfeebeforelastdatethroughCSCSPVorOnlinePaymentorNEFT/RTGS////.

Lefthandthumbimpression/ SignatureofApplicant/Back