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

The document is an online application submitted by Shubham Pal for the CCC examination to be held in May 2020. It contains details of the applicant such as personal information, address, education qualifications, and payment details. The applicant agrees to abide by NIELIT's rules and that the information provided is true to the best of his knowledge.

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Shubham Pal
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83 views1 page

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

The document is an online application submitted by Shubham Pal for the CCC examination to be held in May 2020. It contains details of the applicant such as personal information, address, education qualifications, and payment details. The applicant agrees to abide by NIELIT's rules and that the information provided is true to the best of his knowledge.

Uploaded by

Shubham Pal
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
Demand Note Number 5763109

Demand Note Date 17-Mar-2020


GOCCC6591202 17-Mar-2020 06:28:36 PM

1. Examination Details / पर��� क� �ववरण


Applied for Examination / �कस पर�क्ष� क� �लए आव�दन �कय� CCC - May, 2020 (Every Month Exam Cycle )
Applied As / �कसक� रूप म� आव�दन �कय� Direct
Examination Center1 / पर�क्ष� क�द्र 1 KAN -Kanpur Examination Center2 / पर�क्ष� क�द्र 2 RAE -Raebarely
Appeared in Previous CCC Exam / �पछल� CCCपर�क्ष� No
2. Applicant's Personal Details / आव�दक क� व्य��गत �ववरण
Applicant's full name / आव�दक क� प�र� न�म Mr. Shubham Pal
Father's Name / �पत� क� न�म Mr. Hausila Prasad
Mother's Name / म�त� क� न�म Mrs. Kanchan Pal
Gender / �ल�ग Male Category / वग� Other Backward Class / अन्य �पछ�� वग�
Disability / �दव्य�� गत� No Disability Type / �दव्य�� गत� प्रक�र Not Applicable
Date of Birth / जन्म �दन�� क (dd-MMM-yyyy) 24-Jun-2004 Occupation / व्यवस�य Others / अन्य
Aadhar Card Number / आ��र क�ड� स��� 267XXXXX3511
3. Contact Details / ��पक� �ववरण
Phone with STD code / द� र��ष एस �� ड� क�ड स�हत Mobile Number / म�ब�इल न�बर 8808985493
Email Address / ईम�ल पत� [email protected]
4. Address Details / पत� �ववरण
Address Line1/पत� प��क्त 1 Civil Lines
Address Line2/पत� प��क्त 2 Patel Nagar
Address Line3/पत� प��क्त 3
City Name/शहर क� न�म Fatehpur District / �जल� Fatehpur
State / र�ज्य Uttar Pradesh Pin Code / �पन क�ड 212601
5. Educational / Qualification Details / ����क / ��ग्यत� क� �ववरण
Highest Educational Qualification / उच्चतम श��क्षक य�ग्यत� 10Th Pass
Year of Passing / उत्त�ण� वष� 2019
6. Declaration / ��षण�
I son of Smt Kanchan Pal and Shri Hausila Prasad 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.
म�, ��मत� Kanchan Pal और �� Hausila Prasad क� प�त्र यह ��षण� करत� �� �क स�स�स� पर�क्ष� ह� त� ऑनल�इन आव�दन फ�म� म� म�र� ��र� व�ण�त समस्त ज�नक�र� म�र� ��न और �व��स स� सत्य ह� । म�
र�.इ.स�.प्र�.स�. क� �नयम�� व �व�नयम�� तथ� म�र� पर�क्ष� ह� त� प्रव�श स� स�ब���त र�.इ.स�.प्र�.स�. क� �नण�य�� स� �� सहमत �� । म�झ� ��त ह� �क र�.इ.स�.प्र�.स�. क� उपय��क्त उ���खत �कस� �� प्रक�र क� कथन/ �ववरण असत्य प�य�
ज�न� पर पर�क्ष� म� म�र� उप��थ�त क� प��त �� म�र� प�रण�म र�क� ज�न� क� अ�त�रक्त अन्य क�ई क�र� व�ई ज� उ�चत समझ� ज�ए, अ��क�र ह� । म�झ� ��त ह� �क म�र� पर�क्ष� क�द्र चयन क�लम(1) क� अ�तग�त �कस� �� अन्य
पर�क्ष� क�द्र म� कर�य� ज� सकत� ह� । आग�, म� यह �� समझत� �� �क �कस� �� प्रक�र क� क�रणवश म�र� पर�क्ष� क� अ�न��� रण/अवम���� कन क� ��थ�त म�, म�र� �कस� प्रक�र क� क्ष�त क� �लए र�.इ.स�.प्र�.स�.उत्तरद�य� नह��
ह�ग�।
7. Payment Detail
Fee Details: Exam Fee: 590.00 [Five Hundred Ninety Rupees Only]
Payment Mode: Not Paid Payment Transaction No./��गत�न स��� Not Paid
Last date of fee payment and submission of examination form is 31-Mar-2020 after this date you will not be allowed to submit the examination form. Please pay your fee
before last date through CSC SPV or Online Payment or NEFT/RTGS / अ��तम त�र�ख स� पहल� अपन� फ�स क� ��गत�न स�एसस� क�द्र पर/ऑनल�इन/ एनईएफ��/आर��ज�एस स� कर� .

Left hand thumb impression / ब�ए� ह�थ क� अ�ग��� क� �नश�न Signature of Applicant/ हस्त�क्षर
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