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BHARAT SAFETY TRAINING
ACADEMY OF HEALTH & SAFETY
RKM BUILDING, OFFICE 122, Ist FLOOR, AL QIYADAH, Dubai, UAE
Contact : +971 565344854
Aff your ecent
COURSE APPLICATION & REGISTRATION FORM paspor size
jad cay eke Hing sm, ae cols proved ae maniton) photograph here
(esd cach
‘te Documents to be submited along wid the application:
1: Prof ediaten
2 Riess pot copy of psepor SSC.)
1 AyD pot wt pct
IEMA FOUNDATION CERTIFICATE IN ENVIRONMENTAL MANAGEMENT.
4.__Personal Details:
Name weoaucres: SHIRAZ QUASAIF ‘Age & Date of Birt 41, 1390711982
Religion; ISLAM ‘Nationality: INDIAN (MRIREB | Female Tick) | Mita Status; MITE / Single > (Tick)
Fathers! Husbands /Guaran Name: LATE MD MAHTAB ALAM Contact No: a sxsst0H00
Tress Permanent Present
House Neme SSHAHDA MANZIL EXPERTISE CONTRACTING COMPANY
Post Ofc: BEGUSARAL BAIL
Pave: BEGUSARAL JUBAIL
Dist (State BHAR SAUDI ARABIA
Pin: e5ttot 31961
Phone (Res)
Pane: (Mob) 818877680075 9956054060
ald: shiraz keshfalg@[Link]
2. Qualifications (Proof tobe attach (an Actions! Krowiedoe objid shal be shown below)
‘Cours & inte ‘Speclazaton
BSC, SHOBHIT UNIVERSITY, INDIA FIRE SAFETY HAZARD
MANAGEMENT
Company information
Company Name Address, Designation eee
[Link] CONTRACTING
‘COMPANY (4 YEARS) EHS
‘SUPERVISOR
JUBAIL, SAUDI ARABIA, EHS SUPERVISOR A YEARS BHARAT SAFETY TRAINING
ACADEMY OF HEALTH & SAFETY
RKM BUILDING, OFFICE 122, Ist FLOOR, AL QIYADAH, Dubai, UAE
Contact : +971 565344854
COURSE APPLICATION & REGISTRATION FORM
(etc bere tra am, lo coun prided a a
EXPERTISE CONTRACTING
COWPANY JUBAIL, SAUDIA RABIA EHSSECTIONHEAD |
70
4,_Course Fee Details:
‘Course Sponsored by ? Doher__
i Ud = ie
Payment Mode Deheque a
= a
Declaration
4. thereby declare thatthe above information provide are true to best of my knowiedge 8 bolt,
2. will pay 5% of the registration amount as administration charge Incase of discontinustion of the course aftr the registration
a 3
‘Sinature ofthe Applicant) Date: _sr0a
eee
‘TOBE FILLED DURING THE APPLICATION | REGISTRATION TME: (CENTER CODE: PLACE:
Programme Code Batch Code: ‘Sudent Code
Course Fee Batch Timing
Faculty (8) Prog. Duration
Details of proof collected
‘Any other Remarks: BHARAT SAFETY TRAINING
ACADEMY OF HEALTH & SAFETY
RKM BUILDING, OFFICE 122, Ist FLOOR, AL QIYADAH, Dubai, UAE
Contact : +971 565344854
COURSE APPLICATION & REGISTRATION FORM
ad carta eke Hing is bem, a ie caus vied aw manson)
Data Collected by: Detais Up-dated by
Date’ Date
‘TO BE FILLED DURING THE TME OF ISSUE OF CERTEEICATE:
Coticate No. Date of issue Mode of issue
issued by:
41. (before issuing the certificate please take @ copy of cerca an le the sare) Recelved by:
2 (Ube oats ecaves by ry eer parson n bea the apleaet Opt cony of to
‘ec sallbe cal) nal spr Hom esd sabe cole ane
(ame, signature wih date)
(name & signature) ID PROOF No.