Application Form 2021-22
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Registration
Application Form 2021-22
REGISTRATION APPLICATION FORM FOR COURSE
1. Course Details
*
Mandatory fields
Branch
-Select Branch-
Varanasi
Mirzapur
Course
*
-Select Course-
2. Applicant's Personal Details
Canditate's Name
*
(Full name as per the highest / latest qualification certificate or legal certificate)
Father's /Guardian Name
*
(Full Name As Per Educational/Legal Certificate)
Mother's Name
*
(Full Name As Per Educational/Legal Certificate)
Gender
*
Select Gender
Male
Female
Date of Birth
*
(dd-Mon-yyyy)
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Category
*
--Select One--
General
OBC
SC
ST
Others
Religion
*
--Select One--
Hindu
Muslim
Christian
Sikh
Jain
Buddhist
Others
Nationality
*
Indian
Other
Aadhar Card No.
*
3. Contact Details
Mobile Number
*
Email Address
*
Father's Contact No.
4. Address Details (4A is Correspondence Address) , (4B is Permanent Address)
4A - Address for Correspondence
*
4A - Pincode
*
:
4B - Permanent Address
*
(Copy Address)
4B - State
*
--State--
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra and Nagar Haveli
Daman and Diu
National Capital Territory of Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
4B - District
*
--Select One--
4B - Pincode
*
4. Educational / Qualification Details
S. No.
Name of Exam
Board/University
Passing Year
Institution
Subject
Marks
Percentage
1.
High School
(SSLC) *
%
2.
Intermediate
*
%
3.
Others
%
Parent's Details
Parent's Educational Qualification
*
Select Option
10 (SSLC)
10+2 (Intermediate)
Degree (UG)
Degree (PG)
Diploma
Parent's Employment Details
Name of the Organization
*
Designation
*
Organization Contact No.
*
Address of the Organization
*
5. Upload Photo & Signature
Upload Photo
*
( JPG,JPEG,PNG image with size upto 20 KB )
Upload Signature
*
( JPG,JPEG,PNG image with size upto 20 KB )
Fee
Rs.5000/-
6. Declaration
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I here by declare that the information furnished above is true, complete and correct to the best of my knowledge and belief.
