National Institute of Electronics and Information Technology (NIELIT), Imphal No: (Formerly , DOEACC Centre Imphal) APPLICATION FORM FOR ADMISSION TO SHORT TERM & ESDM COURSES Course interested in :………………………………………………………………. Course Fee :………………………………….. Your passport size Photograph attested by a Gazetted Officer. 1. Aadhaar No: (Tick and write the no.(s)) 2. Name (in block letters): 3. Father’s Name (in block letters): 4. Guardian’s Name (if parents are not alive): 5. Address for correspondence: Pin Mobile : 6. Gender: Male Female 7. Date of birth: Day Month 8. Category: SC ST OBC Year P/H Minority Gen Others 9. Highest Examination Passed/Appeared: ……………………………………………………………… Undertaking (a) My short – term course certificate will not be issued to me if, I, i) attend less than 80 p.c of the classes, or ii) do not pass the exam conducted by NIELIT concerning the short – term course (b) My Caution money deposit …………. (Rupees …………………………..) will not be refunded to me if I attend less than 80 % of the classes. Place:……………………………………… Date:……………………………………… Signature of the applicant For Office use only M.R./DD/Cheque No………………….……… Date………………………. Amount ………………………. Category ……………. Authorized Signatory…………………………………………….