BHARAT SAFETY TRAINING

ACADEMY OF HEALTH & SAFETY

RKM BUILDING, OFFICE 122, 1st FLOOR, AL QIYADAH, Dubai, UAE
Contact : +971 565344854
Affix your recent
COURSE APPLICATION & REGISTRATION FORM passport size
(Read carefully before filling this form, all the columns provided are mandatory) photograph here
Note: Documents to be submitted along with the application:
1. Proof of education
2. Address proof (copy of passport / SSLC, etc...)
3. Any ID proof with photo

Name of Course Applied For: IEMA FOUNDATION CERTIFICATE IN ENVIRONMENTAL MANAGEMENT

1. Personal Details:
Name (IN BLOCK LETTERS): SHIRAZ QUASAIF Age & Date of Birth: 41, 13/07/1982

Religion : ISLAM Nationality: INDIAN Male □ / Female □ (Tick) Marital Status: Married □ / Single □ (Tick)

Father’s/ Husband’s / Guardian Name: LATE MD MAHTAB ALAM Contact No: (Local) +966564054090

Address Permanent Present

House Name SHAHDA MANZIL EXPERTISE CONTRACTING COMPANY

Post Office: BEGUSARAI JUBAIL

Place: BEGUSARAI JUBAIL

Dist. / State BIHAR SAUDI ARABIA

Pin: 851101 31961

Phone: (Res.)

Phone: (Mob) +918877660075 +966564054090

E-mail Id: shiraz.kashifalig@gmail.com

2. Qualifications (Proof to be attached)(Any Additional Knowledge obtained shall be shown below)
Course & Institute Specialization
Year of % of Proof
Passing Marks (Yes/No)
BSC, SHOBHIT UNIVERSITY, INDIA FIRE SAFETY HAZARD 2015 63 YES
MANAGEMENT

3. Company Information
Years of
Company Name Address Designation
experience
JUBAIL, SAUDI ARABIA EHS SUPERVISOR 4 YEARS
1.ANABEEB CONTRACTING
COMPANY (4 YEARS) EHS
SUPERVISOR

Page 1 of 3
 BHARAT SAFETY TRAINING
ACADEMY OF HEALTH & SAFETY
RKM BUILDING, OFFICE 122, 1st FLOOR, AL QIYADAH, Dubai, UAE
Contact : +971 565344854

COURSE APPLICATION & REGISTRATION FORM

(Read carefully before filling this form, all the columns provided are mandatory)

EXPERTISE CONTRACTING
COMPANY JUBAIL, SAUDIA RABIA EHS SECTION HEAD 8+

P.T.O
4. Course Fee Details:
Course Sponsored by ?  Company  Self  other ______________
(please specify)

Payment Mode ?  Cash  Cheque  other ______________

(please specify)

Declaration

1. I hereby declare that the above information provided are true to best of my knowledge & belief .

2. I will pay 50% of the registration amount as administration charge In case of discontinuation of the course after the registration

________________________
(Signature of the Applicant) Date: ______3/9/2023_____________

FOR OFFICE USE ONLY

TO BE FILLED DURING THE APPLICATION. / REGISTRATION TIME: (CENTER CODE: _____________) (PLACE: _________________________________________)

Programme Code Batch Code: Student Code

Course Fee Batch Timing

Faculty (s) Prog. Duration

Details of proof collected

Any other Remarks:

Data Collected by: Details Up-dated by:

Date: Date

Page 2 of 3
 BHARAT SAFETY TRAINING
ACADEMY OF HEALTH & SAFETY
RKM BUILDING, OFFICE 122, 1st FLOOR, AL QIYADAH, Dubai, UAE
Contact : +971 565344854

COURSE APPLICATION & REGISTRATION FORM

(Read carefully before filling this form, all the columns provided are mandatory)

TO BE FILLED DURING THE TIME OF ISSUE OF CERTIFICATE:

Certificate No. Date of Issue Mode of issue

Issued by:
1. (before issuing the certificate please take a copy of certificate and file the same) Received by:
2. (if the certificate is received by any other person on behalf of the applicant ID proof copy of the
recipient shall be collected) (email approval from the student shall be collected and file it)

(name, signature with date)

(name & signature) ID PROOF No.:
.

Page 3 of 3