NSIC TECHNICAL SERVICES CENTRE

CHENNAI 600 032

THE COURSE APPLIED FOR
1 Name. 2 Father's Name/ Guardian's Name 3 Date of birth & age 4 Address for Communication : : : : D : D M M Y Y Y Y yrs

Pin Phone No. 5 Email ID 6 Address - permanent :

Pin Phone No. 7 Whether Hostel facility required 8 Category 9 Educational Qualification(s) : : : Yes No (Tick the option)

SC/ST/OBC/MIN/PH/GEN/Ex.Ser Pl.specify: a. b. c.

10 Experience if any

11 Registration Fee Details

Rs. Bank :

250/Date : / /

DD No.:

12 Signature

Date :

FOR OFFICE USE ONLY

Admitted for the Course Total Fee to be paid Fees paid at the time of admission Caution Money Deposit : : : : Yes Rs. Rs. Rs. Date: Date: / / / / No