Cost Rs.
20/-
For Office use only
BATCH SERIAL
(For Office use only)
NATIONAL INSTITUTE OF ELECTRONICS AND INFORMATION TECHNOLOGY
Electronics Niketan, 6, CGO Complex, New Delhi – 110 003
Phone:011-2436 3330-02, 2436 6577, 79, 80, FAX:011-2436 3335
Email:ccc@[Link], Web site: [Link]
EXAMINATION APPLICATION FORM - CERTIFICATE COURSE ON COMPUTER CONCEPTS –(CCC)
(READ ENCLOSED INSTRUCTIONS CAREFULLY BEFORE FILLING UP THIS FORM)
BOX A. BOX C.
BOX B. STATUS OF CANDIDATE
DIRECT GOVT. RECOG SCHOOL / COLLEGE
Ο Ο
Recent Photograph ACCR. INSTT OTHERS Recent Photograph
35mm x 45mm
Ο Ο 35mm x 45mm
Attested by a BOX D. FEE DETAILS Unattested copy of
Gazetted Officer DD NO Photograph pasted in Box
or DD DATE A.
Bank Officer
AMOUNT (in Rs.)
or
Incharge – NIELIT BANK
Accr. Instt.
BOX E. SIGNATURE OF CANDIDATE
BOX F. Month & Year of Examination
1. NAME - IN CAPITAL LETTERS
2. FATHER’S NAME – IN CAPITAL LETTERS
3. MOTHER’S NAME – IN CAPITAL LETTERS
4. DATE OF BIRTH (in Christian Era) D D M M Y Y Y Y 5. SEX Ο MALE Ο FEMALE
Darken appropriate box
6. HIGHEST QUALIFICATION: (Darken appropriate box AND attach Attested copy of the Certificate, in respect of the Box darkened)
Ο Below 10th Ο 10th Pass Ο 10+2 Ο 10th+ITI Ο Polytechnic Diploma Ο Graduation or higher
7. RESIDENCE DETAILS OF CANDIDATE - IN CAPITAL LETTERS
ADDRESS:
CITY: PIN CODE
STATE:
7.1. CONTACT DETAILS
PHONE NO. EMAIL ID
8. INSTITUTE DETAILS- IN CAPITAL LETTERS 8.1 E-PROV. NUMBER: 9 9
NAME:
ADDRESS:
STATUS OF INSTITUTE: Ο ACCR. INSTTT Ο GOVT. [Link]/COLLEGE Ο OTHERS
9. CENTRE CHOICE First Choice Second Choice
Cost Rs. 20/-
CITY CODE NAME CITY CODE NAME
10. OCCUPATION: (Darken the appropriate box)
Ο Govt. Employed Ο Govt. undertaking Ο Self Employed Ο Other (Please Specify) . . . . . . . . . . . . . . . .
11. CATEGORY: (Darken the appropriate box)
Ο General Ο Scheduled Caste Ο Scheduled Tribe Ο O.B.C.
Ο Handicapped Ο Other Please Specify) . . . . . . . .
12. WHETHER APPEARED PREVIOUSLY IN ‘CCC’ EXAM YES/ NO
If YES, give details of immediate LAST EXAM only
MONTH: YEAR: ROLL NO.:
13. DECLARATION:
I S/o /D/o (Father’s name) hereby declare
that, all the particulars stated in the application, are true to the best of my knowledge and belief. I agree to abide by the
rules and regulations of DOEACC Society and also to the decision of the Examination Authority, regarding my
admission to the examination. I have noted that the Examination Authority 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 made above being found incorrect. I have noted that, I might be required to appear in the examination at
any other centre not specified under centre choice column above.
Place:
Date: Signature of the Applicant
14. TO BE FILLED BY INSTITUTES / GOVERNMENT RECOGNISED SCHOOLS / COLLEGES, CONDUCTING
‘CCC’ COURSES, ONLY
(Refer to the Guidelines for Institutes)
Certification:
Certified that the applicant is / was a bonafide student, of NIELIT - Certificate Course on Computer Concepts (CCC)
during the session from ________________ to ________________ at this institute and has completed course before
the examination, and an amount of Rs. 340/- has been received from him/ her.
Signature:
Name:
Designation: Institute Seal with Address
CHECK LIST OF THE ENCLOSURES
ITEMS Please Darken
appropriate Box
Demand Draft (Examination fee) Ο
Attested Photograph Ο
Unattested Photograph Ο
Attested copy of Mark sheet of Highest Qualification Obtained by the Ο
Candidate