NEBOSH Registration Form (Thowfeek)

the NEBOSH name and NEBOSH logo.
ning Partner logo may be used.

BOSH Blue
tone® 280 C
OSH Learning Partner logo is
Variations
00, M80,Y0,
in Colour, K20
White and Black
and should be reproduced as
G63, B136
X #002B7F
NEBOSH Blue
REGISTRATION FORM
Pantone 280 C
® 698
000 000 000 000
C100, M80,Y0, K20
R2, G63, B136
HEX #002B7F
d Learning Partner 698
000 000 000 000
YK- C15,
Gold
Please
M20,
Learning
provide your soft copy of your Passport size photo
PartnerY100, K5
B- R218, G189, B70
CMYK- C15, M20, Y100, K5
HEX #DABD46Please fill in the required details for registration:

RGB- R218, G189, B70
X #DABD46
Please Tick (√) in the appropriate:
Silver Learning Partner
CMYK- C0, M0, Y0, K40
erRGB-
Learning
R178, G178, Partner
B178
YK- C0, M0, Y0, K40
HEX #b2b2b2 000 000 000 000
B- R178, G178,
Bronze Learning B178
Partner
CMYK- C0, M38, Y76, K20 PERSONAL INFORMATION
X #b2b2b2
RGB- R205, G127, B50
000 000 000 000
HEX #cd7f32
Mr Mrs Miss Dr Others
nze Learning Title
CMYK- C80, M100,
Partner
Corporate Learning Partner
(Please Select in the appropriate column)
Y0, K0
YK- C0,
RGB- R101,M38, Y76, K20
G45, B134
✔
HEX #652D86
B- R205, G127, B50
X #cd7f32 Given Name (As Per Id Proof) MOHAMED THOWFEEK
000 000 000 000
Surname (As Per Id Proof) JALALUDEEN

porate Learning
PleasePartner
tick the appropriate ID proof to be
Passport Copy Driving Licence Aadhaar ID Please Specify:
YK- C80, M100, Y0, K0
enclosed
B- R101, G45, B134 (√)
✔ 755384796336
X #652D86 House Street Name
Number & Address:
RAHMATH
000 GARDEN
000 ,KEEZHA SARAKKALVILAI,KANNIYAKUMARI,TAMILNADU
000 000
64F12
City Country Postal Code Country of Residence
NAGERCOIL INDIA 629002 INDIA
Date of Birth: (DD/MM/YY) Gender: Please Tick (√) Nationality Passport Number
2-Mar-1994 ✔ Male Female INDIAN P6520857
Landline: Mobile Number: Official Number:
8903876599
Emergency Contact Number: E-Mail ID: mthowfeek002@gmail.com
SPECIAL NEEDS OF CANDIDATES

If “YES”(√) provide appropriate Proof
If “NO”(√) mention “Not Applicable”
Do you have any permanent or long YES NO Please Specify:

term disabilities or temporary disability
in performing certain types of work? ✔
Do you have any medical condition or YES NO Please Specify:

specific learning need?
✔
Is English your second language? YES NO Please Specify:

What is your first language?
✔ TAMIL IS MY FIRST LANGUAGE
Page 1 of 4 F/MK/01_V.5.0
The NEBOSH brand is built through the use of the NEBOSH name and NEBOSH logo.
allowed to use the NEBOSH logo without
This document outlines how the NEBOSH Learning Partner logo may be used.
their unique Learning Partner number. NEBOSH Blue
The NEBOSH Learning Partner logo
Pantone® 280 C
Colour
consists of the NEBOSH logo, the status of The NEBOSH Learning Partner logo is
Variations
Use of the NEBOSH the Learning Partner (Gold, Silver, Bronze C100, M80,Y0, K20
available in Colour, White and Black
Learning Partner logo REGISTRATION FORM

Use of the NEBOSH Learning Partner
or Corporate) and a unique Learning
Partner number. Learning Partners are not
their unique logo
Learning Partner number.
variations and should be reproduced as
R2, G63, B136
follows:
HEX #002B7FNEBOSH Blue

698
000
is limited and each NEBOSH Learning Pantone 280 C
®
Use of the NEBOSH C100, M80,Y0, K20

Partner is bound by the terms and Learning Partner logo R2, G63, B136
Use of the NEBOSH Learning Partner logo HEX #002B7F
conditions of the NEBOSH ‘Learning is limited and each NEBOSH Learning Gold Learning Partner 698
000 000 000
PartnerINFORMATION
is bound by the terms and
Partner Agreement’. conditions of the NEBOSH ‘Learning CMYK- GoldC15, M20,
Learning PartnerY100, K5
Partner Agreement’.
RGB- R218, G189, B70
CMYK- C15, M20, Y100, K5
RGB- R218, G189, B70
PRESENT EMPLOYMENT
The NEBOSH (Name of thePartner
Learning Company)
logo
The NEBOSHmust SAI
Learning Partner logoLIFE
must SCIENCES
HEX #DABD46 PRIVATE LIMITED(2019-2020)
HEX #DABD46
be clearly visible and not distorted or
be clearly visible and not distorted or in any way. It must not be
misrepresented Silver Learning Partner
DESIGNATIONmisrepresented in any way. It must incorporated into any other logo.
Silver
CMYK- C0, M0, Y0, K40
Learning
not be PRODUCTION EXECUTIVE
RGB- R178, G178, Partner
B178
incorporated into any other logo. To maintain a high standard of quality and
consistency, the NEBOSH Learning Partner
CMYK- C0, M0, Y0, K40
HEX #b2b2b2000 000 000
TOTAL YEARS OF EXPERIENCE logo must be reproduced from the artwork

2.4 RGB- R178, G178,
Partner
supplied by NEBOSH. In addition it can be CMYK- C0, M38, Y76, K20
To maintain a high standard of downloaded
quality from andthe ‘Learning Partners’ HEX #b2b2b2RGB- R205, G127, B50
000
secure area of the website HEX #cd7f32
OTHER HEALTHconsistency,
& SAFETY the NEBOSH Learning
QUALIFICATION Partner It must
www.nebosh.org.uk.
NO not be
logo must be reproduced from reproduced
the artwork from any other printed or
photocopied source.
Bronze Learning Partner
CMYK- C80, M100, Y0, K0
supplied by NEBOSH. In addition it can be CMYK- RGB-C0,
R101,M38,
G45, B134Y76, K20
ACADEMIC QUALIFICATION The NEBOSH Learning Partner logo is
PETROCHEMICAL HEX #652D86
TECHNOLOGY
downloaded from the ‘Learningavailable Partners’
in eps, png and jpeg formats. RGB- R205, G127, B50
secure area of the website HEX #cd7f32 000 000 000
NAME OF THE www.nebosh.org.uk.

COLLEGE It must not be UNIVERSITY COLLEGE OF ENGINEERING THIRUCHIRAPALLI
reproduced from any other printed or Corporate Learning Partner
SELF SPONSORED (Yes/No)
photocopied source. NO CMYK- C80, M100, Y0, K0
RGB- R101, G45, B134
The NEBOSH Learning Partner logo is
SPONSORING COMPANY (Name of Company & Address to be mentioned) NIL HEX #652D86
available in eps, png and jpeg formats.
000
OUR PRODUCTS
Please select the courses you are applying for:

IOSH MANAGING SAFELY
TRAINING DATE:
NEBOSH International General Certificate in Occupational Health & Safety (IGC)

✔ TRAINING DATE: 27-Mar-2023
LANGUAGE SPECIFIED:
ENGLISH
✔ + TAMIL ENGLISH + MALAYALAM
ENGLISH + HINDI ENGLISH + TELUGU ENGLISH
NEBOSH International Diploma for Occupational Health and Safety

Management Professionals (NEBOSH ID New Syllabus)
International Diploma in Environmental Management (EDip)
NEBOSH HSE Certificate in Process Safety Management (PSM)
IEMA
IEMA Environmental Sustainability Skills for the Workforce
COURSE MODE(√)
✔ E-LEARNING ✔ Virtual Interactive Session
How do you know about NIST?
Website ✔ Google Search Mail

SMS Reference Advertisments
Exhibitions Facebook If Others Plz mention:
Pantone® 280 C
Colour
Variations
Learning Partner logo

REGISTRATION FORM
their unique logo
R2, G63, B136
follows:

698
000
®

Use of the NEBOSH Learning Partner logo HEX #002B7F
conditions of the NEBOSH EXAMINATION
is limited and eachDETAILS
‘Learning NEBOSH Learning(IOSH
Partner is bound by the terms and
MS)Learning Partner
Gold 698
000 000 000
Partner Agreement’. conditions of the NEBOSH ‘Learning CMYK- GoldC15, M20,

Please indicate the unit examination/s for which you are

RGB- R218,
registering. G189, B70 Tick (√)+
*Please
CMYK- C15, M20, Y100, K5
RGB- R218, G189, B70
The NEBOSH Learning Partner logo The NEBOSHmust Learning Partner logo must HEX #DABD46HEX #DABD46
IOSH MSbeExam
clearlyDate
visible and not distorted or in any way. It must not
misrepresented
incorporated into any other logo.
PROJECT
be Exam DatePartner
Silver Learning
CMYK- C0, M0, Y0, K40
misrepresented in any way. It must not be SilverRGB- Learning
R178, G178, Partner
B178
incorporated into any other logo. To maintain a high standard of quality and
CMYK- C0, M0, Y0, K40
HEX #b2b2b2
EXAMINATION DETAILS (NEBOSH IGC)
000 000 000
consistency, the NEBOSH Learning Partner
logo must be reproduced from the artwork RGB- R178, G178,
Partner
To maintain a high standard
Please indicate the unit examination/sof quality
downloaded and
for which you are registering.
from the ‘Learning Partners’ HEX #b2b2b2 *Please Tick (√)+
RGB- R205, G127, B50
000
consistency, the NEBOSH Learning Partner It must not be
www.nebosh.org.uk.
✔ IG1 Examlogo
Datemust 3-May-2023
be reproduced from reproduced
the artwork from any other printed or
photocopied source. IG2 Exam Bronze Date Learning Partner
3-May-2023
CMYK- C80, M100, Y0, K0
R101,M38,
G45, B134Y76, K20
The NEBOSH Learning Partner logo is HEX #652D86
Exam Location: State Country
downloaded from the ‘Learning TAMILNADUPartners’
available in eps, png and jpeg formats. RGB- R205, INDIA G127, B50
secure area of the website HEX #cd7f32 000 000 000
www.nebosh.org.uk.
EXAMINATION DETAILS (NEBOSH ItInternational
must not be Diploma for Occupational Health and Safety Management Professionals)
reproduced from any other printed or Corporate Learning Partner
photocopied source.
Please indicate the unit examination/s for which you are CMYK- C80, M100,
registering. *PleaseY0, K0
Tick (√)+
RGB- R101, G45, B134
UNIT
The ID1
NEBOSH Learning Partner logo is UNIT ID2 HEX #652D86 UNIT ID3
EXAMINATION DETAILS (NEBOSH International Diploma in Environmental Management) 000
Please indicate the unit examination/s for which you are registering. *Please Tick (√)+
UNIT EDI UNIT IDEM 2
EXAMINATION DETAILS (NEBOSH PSM)

NEBOSH HSE Certificate in Process Safety Management
EXAMINATION DETAILS (IEMA)

IEMA Environmental Sustainability Skills for the Workforce
TO BE FILLED BY NEBOSH IGC / IDip / EDip / PSM / IOSH MS / IEMA - RESIT CANDIDATE ONLY
(Mandatory if you attend or regISter with NEBOSH through any courSe provider)
Course Provider Student Number Date/s of Previous Sitting

20-Mar-2023
Certificate Name Confirmation

I read and agree to the name to be displayed as per my given id proof ( )
MOHAMED THOWFEEK JALAUDEEN
Signature of the Candidate
Payment Mode: (Please tick the appropriate box)
Payment Gateway( Debit / Credit Card)

Net banking Gpay / Paytm ✔ CASH PAYMENT STRICTLY NOT ACCEPTED
Payment Details: Online transfer should be done to the bank account given below
Pantone® 280 C
Colour
Variations
Learning Partner logo

REGISTRATION FORM
their unique logo
R2, G63, B136
follows:

698
000
®

conditions of the NEBOSH ‘Learning BANK DETAILS

Use of the NEBOSH Learning Partner logo
is limited and each NEBOSH Learning
HEX #002B7F
Gold Learning Partner 698
000 000 000
Partner is bound by the terms and

Partner Agreement’.Account Name: conditionsNIST INStitute
of the NEBOSH ‘Learning Private CMYK- Limited
GoldC15, M20,
RGB- R218, G189, B70
CMYK- C15, M20, Y100, K5
Bank Branch
The NEBOSH Account
LearningNumber
Partner logo Account
The NEBOSHmust Address
Learning Partner logo must Account
HEX IFSC CODE
RGB- R218, G189, B70
#DABD46
HEX #DABD46 SWIFT CODE
be clearly visible and not distorted HDFC
or bank,
misrepresented in any way. 281, Mount
It must not be Silver Learning Partner
incorporated into any other logo. CMYK- C0, M0, Y0, K40
HDFC Teynampet 15862320000051
misrepresented in any way. It must Road, not beTeynampet, SilverHDFC0001586
Learning
RGB- R178, G178, Partner
B178 HDFCINBB
incorporated into any other logo. Chennai –Learning
600 Partner
018
To maintain a high standard of quality and
consistency, the NEBOSH
CMYK- C0, M0, Y0, K40
HEX #b2b2b2 000 000 000
logo must be reproduced from the artwork RGB- R178, G178,

Partner
TERMS AND CONDITIONS:

To maintain a high standard of downloaded
quality from andthe ‘Learning Partners’ HEX #b2b2b2RGB- R205, G127, B50
000
consistency,
1. During registration, the NEBOSH
registration form,Learning
copy ofPartner
passport
www.nebosh.org.uk. if not
It must notbe a copy of aadhaar card/
logoshould
driving license must be bereproduced
submitted.from photocopied
the artwork
reproduced from any other printed or
source.
Bronze Learning Partner
CMYK- C80, M100, Y0, K0
R101,M38,
G45, B134Y76, K20
2. Language specified training is applicable The only
NEBOSH for NEBOSH
Learning Partner logoIG is virtual training Batches
HEX #652D86
downloaded from the ‘Learningavailable Partners’
in eps, png and jpeg formats. RGB- R205, G127, B50
3. The cancellation
secureof theofcourses
area should be confirmed by the learners
the website HEXthrough
#cd7f32an e-mail. 000 000 000
4. The course www.nebosh.org.uk.

fee will not be refunded at any
It must notcircumstances,
be due to discontinuation / absenteeism by the
learner duringreproduced fromperiod
the training any other printed or Corporate Learning Partner
5. IOSH, IEMA, IGC, PSM - Cancellation prior to the commencement ofCMYK-
photocopied source. training C80,date M100,
(theY0, K0may vary for
date
RGB- R101, G45, B134
each course) will lead to a deduction of 18% GST and 15% of admin cost from the paid course fee. And, the
The NEBOSH Learning Partner logo is HEX #652D86
learning materials cost will be deducted in the refund amount.
6. IDIP & EDIP - Refund of course fees is not permissible if the learner had registered for the course with the 000
initial registration fee and had availed the login credentials to access the study materials.
7. Changes in the training schedule by the learner should be communicated to NIST through email before the
commencement of the training date. NO CHANGES ONCE THE TRAINING BATCH HAS STARTED.
8. Any Batch cancellation made by NIST the paid amount by the candidate will be refunded without any
deduction. For any Batch cancellation or transfer we will communicate prior to the training schedule date.
9. Exam
cancellation/Transfer after the NEBOSH exam closing date the amount would not be refunded at any cost.
10. Fee payment should be made only to NIST Bank Account. NIST is not responsible for any other individual
account transactions.
11. Please ensure to read all the relevant information in learner’s agreement and sign up.
I declare that the information herein is true to the best of my knowledge.
I accept the NIST’s terms & conditions in the application form and understand it is subject to approval.
Signature: Date: 20-Mar-2023
OFFICE USE ONLY
Reference No: Reviewed by: Date:
Month of joining: Approved by: Designation
Head Office - Chennai:

No. 574/3&4, 2nd Floor, (Opp to Anna Arivalayam), Anna Salai, Teynampet, Chennai - 600018.
Website: www.nistinstitute.com E-Mail: info@nistinstitute.com
SOUTH Jharkhand - +91 8637687230 Haryana - +91 9123547200

Tamil Nadu - +91 9677111486 Odisha - +91 8637687224 Punjab - +91 8637687186
Kerala - +91 9150007239
NORTH EAST Uttarakhand - +91 8637687186
Karnataka - +91 9686403779
Andhra Pradesh - +91 8106059783 Arunachal Pradesh, Assam, Meghalaya, Himachal Pradesh - +91 9123547200
Telengana - +91 9177955633 Nagaland, Manipur, Mizoram, Tripura - Jammu Kashmir - +91 8637687186
WEST +91 8637687230
Bangladesh - +91 8637687224
Maharashtra (Mumbai) - +91 9136920879 CENTRAL Nepal - + 91 8637687230
Maharashtra (Pune) - +91 9665434153 Madhya Pradesh - +91 8806259028
Gujarat - +91 8072039765 MIDDLE EAST
Rajasthan - +91 8072039765 Chhattisgarh - +91 9123547200
Abu Dhabi, Dubai, Kuwait,
EAST NORTH Oman, Qatar, Saudi Arabia,
West Bengal - +91 8637687230 New Delhi - +91 8637687186 Bahrain & Yemen -
Bihar - +91 8637687224 Uttar Pradesh - +91 9123547200 +91 78239 59090

NEBOSH Registration Form (Thowfeek)

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NEBOSH Registration Form (Thowfeek)

Uploaded by

Copyright:

Available Formats

the NEBOSH name and NEBOSH logo.

ning Partner logo may be used.

HEX #DABD46Please ﬁll in the required details for registration:

Surname (As Per Id Proof) JALALUDEEN

City Country Postal Code Country of Residence

NAGERCOIL INDIA 629002 INDIA

2-Mar-1994 ✔ Male Female INDIAN P6520857

Landline: Mobile Number: Official Number:

Emergency Contact Number: E-Mail ID: mthowfeek002@gmail.com

SPECIAL NEEDS OF CANDIDATES

Do you have any permanent or long YES NO Please Specify:

Do you have any medical condition or YES NO Please Specify:

Is English your second language? YES NO Please Specify:

Learning Partner logo REGISTRATION FORM

HEX #002B7FNEBOSH Blue

Use of the NEBOSH C100, M80,Y0, K20

TOTAL YEARS OF EXPERIENCE logo must be reproduced from the artwork

NAME OF THE www.nebosh.org.uk.

Please select the courses you are applying for:

NEBOSH International General Certificate in Occupational Health & Safety (IGC)

NEBOSH International Diploma for Occupational Health and Safety

International Diploma in Environmental Management (EDip)

NEBOSH HSE Certificate in Process Safety Management (PSM)

✔ E-LEARNING ✔ Virtual Interactive Session

How do you know about NIST?

Website ✔ Google Search Mail

Learning Partner logo

HEX #002B7FNEBOSH Blue

Use of the NEBOSH C100, M80,Y0, K20

Partner Agreement’. conditions of the NEBOSH ‘Learning CMYK- GoldC15, M20,

Please indicate the unit examination/s for which you are

UNIT EDI UNIT IDEM 2

EXAMINATION DETAILS (NEBOSH PSM)

NEBOSH HSE Certificate in Process Safety Management

EXAMINATION DETAILS (IEMA)

IEMA Environmental Sustainability Skills for the Workforce

Course Provider Student Number Date/s of Previous Sitting

Certiﬁcate Name Conﬁrmation

Signature of the Candidate

Payment Mode: (Please tick the appropriate box)

Payment Gateway( Debit / Credit Card)

Learning Partner logo

HEX #002B7FNEBOSH Blue

Use of the NEBOSH C100, M80,Y0, K20

conditions of the NEBOSH ‘Learning BANK DETAILS

Partner is bound by the terms and

logo must be reproduced from the artwork RGB- R178, G178,

TERMS AND CONDITIONS:

4. The course www.nebosh.org.uk.

Signature: Date: 20-Mar-2023

OFFICE USE ONLY

Reference No: Reviewed by: Date:

Month of joining: Approved by: Designation

Head Office - Chennai:

SOUTH Jharkhand - +91 8637687230 Haryana - +91 9123547200

You might also like

4. The course www.nebosh.org.uk.