1. No category

No:
National Institute of Electronics and Information Technology
Imphal
APPLICATION FORM FOR ADMISSION TO LONG TERM COURSE
(Please refer to prospectus for instructions to fill up the form)
1.Course applied for : DECE/DCSE/PGDCA/ O-level/
A-level/CHM-O/CHM-A/BCA/MCA/MAT-O
(a). If applied for more than one course in separate forms,
give name of preferred course.
(Write Course Name)
Your passport
size
Photograph
attested by a
Gazetted
Officer.
2. Name (in block letters):
3.
Aadhaar No.:
4. Father’s Name (in block letters):
5. Mother’s Name (in block letters):
6. Guardian’s Name (if parents are not alive):
7. Address for correspondence:
Pin
Pin
-
Phone :
8. Permanent address:
Mobile :
Pin
Phone :
Mobile :
9. Gender:
Male
Female
0
10. Date of birth:
Day
11. Category:
SC
Month
ST
OBC
Year
P/H
Minority
Gen
Others
12. Religion
13. State of domicile
M.R. No……………
For Office use only
Date…………. Category …………….
Authorized Signatory…………………….
14. Examination Passed/Appeared:
Board/Univ.
Examination
passed/appeared
Year of passing/
appearing
% Marks (if applicable)
Math
Science
Overall
Percentage
Class/
Division
Comp. Sc
I hereby declare that the above information is true to the best of my knowledge and belief. I also undertake that
if I am selected and admitted, I shall abide by the rules and regulations of NIELIT, Imphal as conveyed from
time to time, failing which I may be expelled from the Centre.
Place:
Date:
Signature of the Applicant
15. List of enclosures:
a)
Copy of Aadhaar Card
b)
Age proof certificate
c)
Caste/ Tribe/OBC/ P/H certificate, etc. (if applicable)
d)
Qualifying certificates & mark sheets.
e)
…………………………………………………….
Signature of Parent/Guardian
NIELIT IMPHAL
No.
ADMIT CARD

Name of the course: DECE/DCSE/PGDCA/ O-level/
A-level/CHM-O/CHM-A/BCA/MCA/MAT-O
1.
(Write Course Name)
Your passport
size
Photograph
attested by a
Gazetted
Officer.
(a). If applied for more than one course in separate forms,
give name of preferred course.
2. Name:
(in block letters as in the application form)
Signature of the Candidate
do not write anything below this line.
…………………………………………………………………………………………………………………….
(Sl. No. 3 to 5 to be filled in by office)
3. Roll No.
4. Venue for entrance test :
………………………………………………………………………………………
: ...
……………………………………………………………………………………
5. Date of entrance test
:
………………………………………………………………………………………
6. Reporting time
: 9. 30 a.m.
7. Test duration
: 10 a.m. to 12 noon
(Co-ordinator of Examination)