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)