REGISTRATION-CUM-ADMISSION FORM (KAUSHAL VIKAS)
Candidate Recent
Colour Photograph
For Office Use Only
Centre Name: ___________________________ Centre Code: ______________ Batch No.:____________
आवेदक का नवीन
Batch Start Date: __________________________ Batch Time: ___________________
Name of course:
Candidate Name:
CCCA
CCCFA
रं गीन छाया Jच5
CCHN
CCM
____________________________________________________________________________
In Capital Letters
आवेदक का नाम
पता का नाम
Father’s name:
माता का नाम
____________________________________________________________________________
Mother’s name:
_______________________________________________________________
ज*म तथी
_ _/_ _/_ _ _ _
Date of Birth:
Gender:-M/F
आधार सं1या
2लंग प.ु / !5ी.
Aadhar No:
Permanent Address:
!थायी पता
_________________________________________________________________
________________________________________________________
Present Address:
वत
मान पता
______________________________________________________________________________
_______________________________________________________________________
Mobile No./Tel No.:
दरू भाष सं1या
Nationality:-
E-mail-…………………………………………………
____________________
रा78यता
Matric/10th Registration No.:_________________
मै8क/10 वीं पंजीकरण सं1या
Educational Qualification शै:णक यो;यता :
S.N
Exam Passed
सं.
उीण
परा
1.
Matric हाई!कूल
2.
Intermediate इ&टर
3.
Graduation !नातक
4.
Post-Graduation !नाकोर
5.
Others अ*य
Year of
Passing वष
Board/Univ.
Subject
% of Marks
Division
व0 व0/ बोड
वषय
तशत
ेणी
Any Other Information: ________________________________________________________________________________
अतXरYत जानकार
___________________________________________________________________________________________________________
घोषणा :
DECLARATION:
I ____________________________________________S/O/D/O___________________________________
Here by declare that all the particulars stated above in the application are true to the best of my knowledge
and belief.
मM _______________________________________ पु5/प5
ु ी ी __________________________________
यह घोषणा करता हूँ / करती हूँ Qक आवेदन-प5 मS द गयी सभी जानकारयाँ मेर जानकार के अनस
ु ार सTय एवं
वVवास करने यो;य है |
Date: ______________
Place: ______________
( आवेदक के ह!तार )
(Signature of Candidate)
संल;नक के अनुसार सह [√] का Jच*ह लगाये
Checklist For enclosure Tick [√]
1. Declaration Signed
घोषत ह!तार
2. Self Attested photo copy of Aadhar Card
आधार काड
का !व-सTयापत छाया त
3. Self attested photo copies of Marks sheets.
अंक प5^ का !व-सTयापत छाया तयाँ
Left Hand Thumb Impression of
Candidate
(आवेदक के बायाँ
हाथ के अँगठ
ू े का नशान)
For Centre Use Only
We have verified above information with the originals. All above information in this application form is found
correct.
Date:
Centre Seal
Verifying Person Name & Signature: _____________________