certificate examination form

National Institute of Electronics and Information Technology Department of Electronics and Information Technology, Ministry of Communications and Information Technology, Government of India Online Examination Application Form: Course on Computer Concepts(CCC) Application Number Application Date & Time For Office Use Only DLCCC0018925 23May2015 10:43:15 PM Demand Note Number 612698 Demand Note Date 23May2015 1. Examination Details / पर䴀ा का ववरण Applied for Examination / कस पर䴀ा क लए आव दन कया CCC July, 2015 (Every Month Exam Cycle ) Applied As / कसकपमआव दन कया Direct Examination Center1 / पर䴀ा क 1 NDL Delhi Examination Center2 / पर䴀ा क 2 LNW Lucknow Appeared in Previous CCC Exam / पछल CCCपर䴀ा No 2. Applicant's Personal Details / आव दक का यितगत ववरण Applicant's full name / आव दक का प रा नाम Mr. Abhishek Verma Father's Name / पता का नाम Mr. Suraj Prasad Verma Mother's Name / माता का नाम Mrs. Bindeshwari Verma Gender / ल ग Male Category / वग Other Backward Class / अय पछड़ा वग Date of Birth / जम दना क (dd/mm/yyyy) 10Jul1992 Occupation / यवसाय Others / अय Aadhar Card Number / आधार काड स 䴀या 434769920840 3. Contact Details / स पक ववरण Phone with STD code / द रभाष एस ट डी कोड सहत Mobile Number / मोबाइल न बर 9599690476 Email Address / ईम ल पता [email protected] 4. Address Details / पता ववरण Address Line1/पता प ित 1 56 VillMajhigwan Post Banni Address Line2/पता प ित 2 Khraila ThanaManpur Address Line3/पता प ित 3 TehBiswan City Name/शहर का नाम Sitapur District / िजला Sitapur State / राय Uttar Pradesh Pin Code / पन कोड 261145 5. Educational / Qualification Details / श 䴀क / योयता का ववरण Highest Educational Qualification / उचतम श 䴀क योयता Graduation Or Higher Year of Passing / उतीण वष 2014 6. Declaration / घोषणा I son of Smt Bindeshwari Verma and Shri Suraj Prasad Verma hereby declare, that, the particulars submitted by me in the online examination application form of CCC are true to the best of my knowledge and belief. I agree to abide by the rules and regulations of NIELIT and also to the decision of NIELIT regarding my admission for the examination. I have noted that, NIELIT has the right to withhold my result even after my appearing in the examination in addition to any other action as may be deemed fit in the event of any of the statements/particulars made above being found incorrect. I have noted that, I might be required to appear in the examination at any other examination centre not specified under examination centre choice column (1). I further understand that, in the event of nonconduction / nonevaluation of my examination due to any reason whatsoever, I will not held NIELIT responsible for any damages. म , ीमती Bindeshwari Verma और ी Suraj Prasad Verma का प यह घोषणा करता ह क सीसीसी पर䴀ा ह तऑनलाइनआव दनफाममम र वारा वण त समत जानकार म रानऔरव䴀वासससय ह । म रा.इ.स .ौ.स . क नयम व वनयम तथा म र पर䴀ा ह त व शसस ब 䴀धत रा.इ.स .ौ.स . क नण यसभीसहमतह । म झातह क रा.इ.स .ौ.स . कोउपय त उिलखत कसी भी कार का कथन/ ववरण असयपायजान परपर䴀ामम र उपिथत कप䴀चात भी म रापरणामरोकजानकअतरतअयकोईकार वाई जो उ䴀चत समझी जाए, अ䴀धकार ह । म झातह क म र पर䴀ा क चयन कॉलम(1) कअ तग त कसी भी अय पर䴀ा क मकरायी जा सकती ह । आग , मयह भी समझता ह क कसी भी कार ककारणवश म र पर䴀ा कअनधा रण/अवम या कन क िथत म , म र कसी कार क 䴀त क लए रा.इ.स .ौ.स .उतरदायी नह होगा। 7. Payment Detail Fee Details: Exam Fee: 360.00 [Three Hundred Sixty Rupees Only] Payment Mode: Not Paid Payment Transaction No./भ गतान स 䴀या Not Paid Last date of fee payment and submission of examination form is 31May2015 after this date you will not be allowed to submit the examination form. Please pay your fee before last date through CSC SPV or Online Payment or NEFT/RTGS / अ तम तारख स पहलअपनीफसकाभ गतान सीएससी क पर/ऑनलाइन/ एनईएफट/आरटजीएससकर . Left hand thumb impression / बाए हाथकअ ग ठकानशान Signature of Applicant/ हता䴀र Back

certificate examination form

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