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Certificate Examination Form

Ms. Shivani Devi Pal has applied for the CCC examination scheduled for October 2021 through her approved institute New Mahendra's Era located in Barabanki, Uttar Pradesh. She has provided her personal, contact, address, and educational details in the application form and declared that the information submitted is true and correct. She has agreed to abide by NIELIT's rules and regulations regarding admission to the examination.

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AJEET KUMAR
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56 views

Certificate Examination Form

Ms. Shivani Devi Pal has applied for the CCC examination scheduled for October 2021 through her approved institute New Mahendra's Era located in Barabanki, Uttar Pradesh. She has provided her personal, contact, address, and educational details in the application form and declared that the information submitted is true and correct. She has agreed to abide by NIELIT's rules and regulations regarding admission to the examination.

Uploaded by

AJEET KUMAR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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National Institute of Electronics and Information Technology

Ministry of Electronics and Information Technology, Government of India

Online Examination Application Form: Course on Computer Concepts(CCC)


Application Number Application Date & Time For Office Use Only

   

GOCCC7732743 17-Aug-2021 03:07:33 PM

   

1. Examination Details / परीक्षा का विवरण    


Applied for Examination / किस परीक्षा के लिए आवेदन किया CCC - October, 2021 (Every Month Exam Cycle )
Applied As / किसके रूप में आवेदन किया Institute State of Approved Institute / मान्यता प्राप्त Uttar Pradesh
संस्थान के राज्य का नाम
Centre Name of Approved Institute / मान्यता 88004161 - New Mahendra's Era , Barabanki
प्राप्त संस्थान के कें द्र का नाम
Examination Center1 / परीक्षा कें द्र 1 BRK -Barabanki Examination Center2 / परीक्षा कें द्र 2 LNW -Lucknow
Appeared in Previous
CCC
 Exam / पिछली CCCपरीक्षा No
2.
Applicant's Personal Details / आवेदक का व्यक्तिगत विवरण
Applicant's full name / आवेदक का पूरा नाम Ms. Shivani Devi Pal
Father's Name / पिता का नाम Mr. Santosh Kumar Pal
Mother's Name / माता का नाम Mrs. Maya Pal
Gender / लिंग Female Category / वर्ग Other Backward Class / अन्य पिछड़ा वर्ग
Disability / दिव्यांगता No Disability Type / दिव्यांगता प्रकार Not Applicable
Date of Birth / जन्म दिनांक (dd-MMM-yyyy) 11-Mar-2002 Occupation / व्यवसाय Others / अन्य
Aadhar Card Number / आधार कार्ड संख्या 938XXXXX6572
3. Contact Details / संपर्क विवरण
Phone with STD code / दूरभाष एस टी डी कोड सहित Mobile Number / मोबाइल नंबर 9670611861
Email Address / ईमेल पता newmahendrasera[at]gmail[dot]com

4. Address Details /  पता विवरण


Address Line1/पता पंक्ति 1 130 Ashok Nagar
Address Line2/पता पंक्ति 2 Somaiya Nagar
Address Line3/पता पंक्ति 3 Dhakuli
City Name/शहर का नाम Barabanki District / जिला Barabanki
State / राज्य Uttar Pradesh Pin Code / पिन कोड 225123
5. Educational / Qualification Details / शैक्षिक / योग्यता का विवरण
Highest Educational Qualification / उच्चतम शैक्षिक योग्यता 10Th Pass
Year of Passing / उत्तीर्ण वर्ष 2017
6. Declaration / घोषणा

I daughter of Smt Maya Pal
and Shri Santosh Kumar Pal
hereby declare, that, the particulars submitted by me in the online examination application form of CCC
are true to the
best of my knowledge and belief. I agree to abide by the rules and regulations of NIELIT and also to the decision of NIELIT regarding my admission for the examination. I have noted
that, NIELIT has the right to withhold my result even after my appearing in the examination in addition to any other action as may be deemed fit in the event of any of the
statements/particulars made above being found incorrect. I have noted that, I might be required to appear in the examination at any other examination centre not specified under
examination centre choice column (1). I further understand that, in the event of non-conduction / non-evaluation of my examination due to any reason whatsoever, I will not held
NIELIT responsible for any damages.

मैं, श्रीमती Maya Pal


और श्री Santosh Kumar Pal
की पुत्री यह घोषणा करती हूँ कि सीसीसी परीक्षा हेतु ऑनलाइन आवेदन फार्म में मेरे द्वारा वर्णित समस्त जानकारी मेरे ज्ञान और
विश्वास से सत्य है। मैं
रा.इ.सू.प्रौ.सं. के नियमों व विनियमों तथा मेरी परीक्षा हेतु
प्रवेश से संबंधित रा.इ.सू.प्रौ.सं. के निर्णयों से भी सहमत हूँ। मुझे ज्ञात है कि
रा.इ.सू.प्रौ.सं. को उपर्युक्त उल्लिखित किसी भी प्रकार का कथन/ विवरण असत्य
पाये जाने
पर परीक्षा में मेरी उपस्थिति के पश्चात भी मेरा परिणाम रोके जाने के अतिरिक्त अन्य
कोई कार्रवाई जो उचित समझी जाए, अधिकार है। मुझे ज्ञात है कि मेरी परीक्षा कें द्र चयन
कॉलम(1) के अंतर्गत किसी भी
अन्य परीक्षा कें द्र में करायी जा सकती है। आगे,
मैं यह भी समझता हूँ कि किसी भी प्रकार के कारणवश मेरी परीक्षा के अनिर्धारण/अवमूल्यांकन
की स्थिति में, मेरी किसी प्रकार की क्षति के लिए रा.इ.सू.प्रौ.सं.उत्तरदायी
नहीं होगा।
7. Payment Detail
Fee Details: Exam Fee: 590.00 [Five Hundred Ninety Rupees Only]
Payment Mode: Not Paid Payment Transaction No./भुगतान संख्या Not Paid
Submission of examination form is 31-Aug-2021 and Last date of fee payment is 31-Aug-2021 .
Note * Please deposit fee / submit (as applicable) for exam form at the following Address till last date / अंतिम तारीख तक कृ पया निम्न पते पर शुल्क / परीक्षा फार्म (जो लागू हो) जमा करें:-
Approved Centre Name:- New Mahendra's Era , NEW MAHENDRA'S ERS C-243 CIVIL LINE NEAR PETROL PUMP BUS STOP BARABANKI ,PIN CODE-225001 , BARABANKI (
Uttar Pradesh )
Pin Code / (पिन कोड): 225001, Phone Number / (फोन नंबर) : 9670611861

 
Left hand thumb impression / बाएं हाथ के अंगूठे का निशान Signature of Applicant/ हस्ताक्षर
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