Form No. National Institute of Electronics & Information Technology (NIELIT), Delhi Centre (DeitY, MCIT, Govt. of India) 2nd Floor,Parsvnath Metro Mall, Inderlok Metro Station, Inderlok, New Delhi-110052 Application Form for Registration &Examination (For office use only) Verified By: _________________ (Signature) PASTE SIGNED PASSPORT SIZE PHOTOGRAPH (Do Not Staple) Subject Name : ________________________________________________________ Module No & Code : SS101 SS {Please tick at appropriate place} Examination Centre Choice {please Please refer to table below for choice of Examination Centre} S. No. 1 Examination Centre NIELIT Centre AJMER 2. NIELIT Centre CHANDIGARH 3. NIELIT Centre DELHI 4. NIELIT Centre LUCKNOW Address Jain Palace, Sapnda Road, Kekri, District Ajmer Pincode 305404 C-134 (PUNCOM Building)Industrial Area, Phase8, S.A.S.Nagar Mohali-160071 2nd Floor, parsvnath Metro Mall, Inderlok Metro Station, Inderlok,Delhi-110052 Sumit Complex, A-1/9, Vibhuti Khand, Gomti Nagar , Lucknow , UP-226010 5 NIELIT Centre JAMMU New Campus University of Jammu, Dr. BR Ambedkar Road Jammu-180004 6 NIELIT Centre PATNA 13th Floor A-5 Biscoman Tower,Gandhi Maidan, Patna Guwahati main centre: 1st & 2nd Floor, Vittiya Bhavan, AFC Building, Md. Shah Road Paltan Bazar, Guwahati - 781008, ASSAM 7 NIELIT Centre GUWAHATI 8 NIELIT Centre KOLKATA Jadavpur University Campus, Kolkata-700 032, India 9. NIELIT Centre CALICUT Post Box No:5, NIT Campus P.O., Calicut-673601, Kerala 10. NIELIT Centre CHENNAI 25, ISTE Complex Gandhimandapam Road Anna University Campus Chennai- 600025 11 NIELIT Centre AURANGABAD CEDTI Complex, University Campus Aurangabad-431004 Name (Mr./Ms.) {Block Letters} Father's Name (Sh.) Mother’s Name (Smt) Date Of Birth ‘F’ for Female 5.Gender D D M M Y Y ‘M’for Male Y Y Email Id Mobile Aadhaar No. Category General / Religion Hindu/ SC/ Sikh/ ST/ OBC Parsi/ (Kindly tick the appropriate box) Muslim/ Budhist/ Christian/ Other (Kindly tick the appropriate box) Nationality Indian/ If Other, please specify Other _________________ Educational Qualification* S. No. Degree/Certificate Branch/Discipline Percentage Year of Passing Name of Institution Board/University 1. 2. 3. 4. Experience Details * S. No. Organization Name Designation Nature of Job Worked From Worked Till (dd/mm/yyyy) (dd/mm/yyyy) 1. 2. 3. 4. Total Experience *Candidate should ensure that they meet the eligibility criteria. Communication Address: _________________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Pin Code: _____________________ Phone: ________________________ Experience Permanent Address: _________________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Pin Code: _____________________ Phone: ________________________ Fee Detail: DD no. Date Bank Amount Documents to be attached (Please tick ) : ( All documents /Certificates must be attested) 1. 2. Two passport size recent photographs Attested copy of 10th pass certificate in support of Date of Birth. 3. Attested copy of certificate of Educational eligibility 4. Attested copy of experience certificate 6. Copy of aadhar ID Demand Draft 7. Declaration: 1. I solemnly affirm that the information furnished above is true and correct in all respects. I have not concealed any information. I realize that if any information furnished herein is found to be incorrect or untrue, I shall be liable to Criminal prosecution. Further, that my candidature for Examination is liable to be cancelled at any stage. 2. I have ensured that I meet the eligibility criteria, failing, which i shall not be allowed to sit in exam. Place (Signature of the Candidate with Date)
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