Skill Development & Industrial Training Department.

ITI admission form for 2023

Registration No - ICA232317668802

Personal Information

Candidate Name Ajay Date of Birth 25/10/2005

Family Id 4jri8757 Member Id NLXXXXX

Gender Male Blood Group ---

Marital Status UnMarried Aadhaar No. XXXXXXXX5451

e-mail ajaykashya@[Link] Mobile No. 8221985437

Mother's Name Monika Father's / Husband's Name Mukesh

Mother Occupation Homemaker Father Occupation Other labour

Permanent Address [Link].H No 19, Street LOHARI ALI PATTI, Landmark VPO BATTA KAITHAL, District KAITHAL , KALAYAT BL , KAITHAL ,
HARYANA , 136117
Correspondence Address [Link].H No 19, Street LOHARI ALI PATTI, Landmark VPO BATTA KAITHAL, District KAITHAL , KALAYAT BL , KAITHAL ,
HARYANA , 136117

Telephone No. --- BPL Card No. ---

Religion Hinduism Nationality Indian

Country INDIA State HARYANA

District KAITHAL Block / Municipality KALAYAT BL

Guardian Name --- Guardian Mobile No.: --- Guardian e-mail: ---

Are you a Resident of Haryana or Yes Parental Income from all Sources More than Rs 1,00,000 and less than or equal to
Domicile Holder of Haryana? Rs 1,50,000

Education Qualification

Stream : 12th
Exam School Result Passing Marks Max.
Passed Univ /Board /College Roll no Status Year obta/CGPA Marks %tage

12th Central Board of Secondary Education CBSE 17668802 Pass 2023 291 500 58.2
(CBSE)

10th Haryana Board of School Education HBSE 10213562 Pass 2021 500 500 100
94
Subject Wise Marks Detail of 10th

Subject Name Marks Obtained Maximum Marks

ENGLISH 100 100

MATHEMATICS 100 100

SCIENCE 100 100

Reservation Detail

Reservation Category Backward Class

Caste Category Backward Class-A

Caste Jhimar

Divyang Category ---

1. Are you a Resident of Haryana Yes

OR
Do you have Completed 10th class from a school situated in Haryana?

2. Are you from Minority Community? No

Weightage Detail

1 Are you a widow or ward of widow? No

2 Are you Orphan? No

3 Are you Applying for Gram Panchayat Weightage? No

Gram Panchayat ---

Documents Attached

[Link] Document Name

1 Matric (10th Class)

2 Senior Secondary (12th Class)

Choice of Trade Preferences

Preference No. ITI Trade Trade Section

1 GITI Kaithal, KAITHAL Mechanic (Motor Vehicle) Mechanic (Motor Vehicle) NCVT

2 GITI Kaithal, KAITHAL Electrician Electrician NCVT

3 GITI Kaithal, KAITHAL Wireman Wireman NCVT

Fess Detail

Amount Tracking Id Bank Ref. No. Order Status Payment Mode Payment Date Transaction Id

100 11291825165 097851 success Debit Card 2023-06- 232317668802220

4 22T11:09:42 62023110941991
 (I solemnly declare that the above information is absolutely true to the best of my knowledge
and belief. I also know that if any detail given in my application form are found to be false
then my admission will be cancelled. I am aware of the fact that I have to timely deposit fees
and other dues in the institute. I have to follow proper discipline of the institute. I will have to
take due care of tools/ equipments issued to me and I will not leave the course till its
completion.
I further admit that if I do not follow the above instructions then the institution has the
authority to recover the amount spent on my training or any suitable amount decided by
institute).
मैं प्रमाणित करता/ करती हूँ की उपरोक्त दी गई सूचना मेरी जानकारी तथा विश्वास के अनुसार बिलकु ल सत्य है I मैं ये भी
जानता/ जानती हूँ कि यदि आवेदन पत्र मे कोई विवरण असत्य पाया गया तो मेरा प्रवेश रद्द कर दिया जाएगा I मैं इस
बात से परिचित हूँ की मुझे संस्थान में फीस व अन्य राशि जमा करवाने और मुझे प्रशिक्षण संस्थान/ कें द्र के अनुशासन के
अनुकू ल चलना होगा और उन औजारों का जो मेरे पास होंगे मुझे उनका पूरा-पूरा ध्यान रखना होगा और मैं अपने
प्रशिक्षण समाप्त होने तक कोर्स नहीं छोडूंगा/ छोडूंगी |
मैं आगे स्वीकार करता/ करती हूँ की यदि मैं उपरोक्त वचन का पालन नहीं करूँ गा/ करुँ गी तो संस्थान का अधिकार होगा
की मुझसे प्रशिक्षण पर व्यय की गई रकम वसूल कर ले या ऐसी रकम जो संस्थान उचित समझेगी |

Student Signtaure
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