Centre for Environmental Health and Safety
APPLICATION FORM
Please Note:
1. Please complete all the information accurately.
2. It is assured that your data will be stored in a secure way and will only be shared with placement and
authorised government agencies upon your request. This form is a deemed consent for the same.
3. For details for the programme, please visit [Link] Pay the Programme fee on:
[Link] as per the details given on "Programme fee
details".
4. Full refund will be made if the Institute rejects any application.
5. You are required to enclose soft (scanned) copies of all relevant testimonials along with the registration
form.
The completed application form should be emailed to the Director, Centre for Environmental Health and
Safety, C-6, Qutab Institutional Area, Near Old JNU Campus, New Delhi-110016, India to email ID
info@[Link]
Phone: +91 11 26512850
Application Details
Amount Rs.:
Demand Draft/CHQ No.: Affix a recent
Dated: coloured passport
Bank: size photograph
NEFT reference no:
Credit/debit card transaction ID:
Registration Number
(Leave this space blank)
*Crossed DD or Cheque should be in favour of “Institute of Good Manufacturing Practices India” payable at
New Delhi. Please write your name and address at the back of DD/Cheque.
PERSONAL INFORMATION
1. Programme
2. Mode
3. Full Name
4. Address of correspondence (in capital letters)
Postal code/Zip code
5. Mobile no
6. Date of Birth D D M M Y Y Y Y 7. Gender 8. Nationality
9. Mother’s Name
10. Father’s Name
11. Email Id
12. Phone no with STD code
13. Category
(SC: Scheduled Caste; ST: Scheduled Tribe; PH: Physically Handicapped; EWS: Economically Weaker
Sections; Ex-servicemen)
WORK EXPERIENCE
14. Work Experience (If any)
i. Total work experience Year Months
ii. List all your work
From To Total completed Name the Designation Brief job profile
months organization
ACADEMIC QUALIFICATIONS
15. Pre-Bachelor’s Degree Examination(s)
Std. School/ Board/ Year % Marks Class/
Institute University Completed Obtained Division
10th
High School
12th
Intermediate
16. Bachelor’s Degree Examination(s)
Degree Obtained Subject/Specialization
College/Institute University
Year Marks considered for award of Class/Division in Bachelor’s
To
From (DD/MM/YYYY) CGPA/ % of Marks obtained/ Grade
(DD/MM/YYYY)
17. Post-Graduation Degree/Diploma (if any)
Degree Obtained Subject/Specialization
College/Institute University
Year Subject % of Marks obtained
From To
(DD/MM/YYYY) (DD/MM/YYYY)
18. Professional qualification (if any)
Degree Obtained Subject/Specialization
College/Institute University
Year Subject % of Marks obtained
From To
(DD/MM/YYYY) (DD/MM/YYYY)
DECLARATION
I have carefully filled up all the information and agree to abide by the decision of the IGMPI, New Delhi authorities
regarding my registration. I certify that the particulars given by me in the form are true to the best of my knowledge and
belief.
Date Name
Place Signature