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For Office use only

BATCH SERIAL

BOX B. STATUS OF CAND ID ATEDIRECT GOVT. RECOG SHOOL /COLLEG E ACC R. I NST T OTHERSBOX D. FEE DETAILA

DD NODD DATE

AMOUN T ( in Rs.) BANK

D D M M Y Y Y Y

EMAIL ID 9 9 0 1 2 0 4

C E N T R F O R A D V A N C E D T E C H N O L OG I E S 5 0 1/ B PA N N A CH A M B E R S

nd

2 F L O O R S H I V A J I R O A D P U N E

Cost Rs.20/-

DOEACC/7.5.1/F203/R3

Form No.

(For Office use only)

BOX A.

Recent Photograph

35mm x 45mm

Attested by a

Gazetted Officer

or

Bank Officer

or

Incharge - DOEA CC

Accr.Instt.

DOEACC SOCIETY Electronics Ni ketan, 6 CGO Complex, New Delhi - 110 00 3

Phone:011-2436 3330- 02, 2436 6577, 79, 80, FAX:011-2436 3335Email:ccc@doeacc.edu.in. Web site: http://www.doeacc.edu.in

EXAMINATION APPLICATION FORM - CERTIFICATE COURSE ON COMPUTER CONCEPTS-(CCC) (READ ENCLOSED INSTRUCTIONS CAREFULLY BEFORE FILLING UP T HIS FORM)

BOX C.

Recent Photograph

35mm x 45mm

Unattest ed copy of

Photograph pasted in Box

A.

BOX F. Month & Year of Examinati on

1. NAME - IN CAPITAL LETTER S

BOX E. SIGNATURE OF CAND IDATE

October - 2013

2. FATHER'S NAME - IN CAPITAL L ETTERS

3. MOTH ER'S NAME - IN CAPITAL LE TTERS

4. DATE OF BIRTH (in C hris tian Era) 5. SEX MALE FEMA LEDarken appropriate box

6. HIGHEST QUALIFICATION: (Darken appropriate box AND attach Attested copy of the Cert ificate, in respect of the Box Dark ened)

Below 10th

10thPass 10+2 10

t+h

ITI Polytechnic Diploma Graduation or higher

7. RESIDENCE DETAILS OF CANDIDATE - IN CAPITAL LETTERS

ADDR ESS :

CITY:

STATE:

7.1.CONTACT DETAILS

PHONE NO.

PIN CODE

8.INSTITUTE DETAILS-IN CAPI TAL LETTERS

NAME:

ADDRESS:

8.1 E-PRO V.NU MBER:

STATUS OF INSTITUTE: ACCR. INST. GOVT. RECOG. SCH OOL /COLLEGE OTH ERS

9. CENTR E CHOICE First Choice Second Choice

CITY CODE NAME CITY CODE NAME

mailto:Email:ccc@doeacc.edu.inhttp://www.doeacc.edu.in/http://www.doeacc.edu.in/http://www.doeacc.edu.in/mailto:Email:ccc@doeacc.edu.in

7/29/2019 CCC_FORM.pdf

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10. OCCUPATION: (Darken the appropriate box)Form No.

Cost Rs.20/-

DOEACC/7.5.1/F203/R3

G ovt.Employed Govt. Undertaking Self Employed Other (Please Specify)....................11. CATEGORY: (Darken the appropriate box)

General Scheduled Caste Scheduled Tribe O.B.C.

HandicappedOther Please Specify............ 12. WHETHER APPEARED PREVIOUSLY IN 'CCC' EXAM YES/NOIf YES, give details of immediate LAST EXAM only

Month: Year : Roll No.:

13. DECLARATION:

I S/o/D/o (Father's nam e)

hereby declare that, all the particulars state d in the application , are true to the best of my knowled ge

and belief. I agree to abid e by the rules and regul ation of DOE A CC So ciety and also to the deci sio n

of the Exa minati on Autho rity, regarding my admi ssion to the exa min ation. I ha ve noted that theexamination Autho rity has the right to withh old my result ev en after my appea ring in the

Examination in addition to an y other a ction as may be deem ed fit in the event of an y of the

statements mode abo ve being fo und inco rrect. I have no ted that. I might be required to appe ar in

the examination at any othe r centre not specified unde r centre choice column ab ove.

Place:

Date: Signature of the Applicant

14. TO BE FILLED BY INSTITUTES/GOVERNMENT RECOGNISED SCHOOLS/COLLEGES, CONDUCTING

'CCC' COURSES, ONLY

(Refer to the Guidelines for Institutes)

Certification:

Certified that the applicant is / was bonafide student, ofDOEACC - Certificate Course on Computer Concepts

(CCC) during the session from August 2013 to October 2013 at this institute and has completed coursebefore the examination, and an amount of Rs. 340/- has been received from him/her.

Signature:

Name: Avinash Wadkar

Designation : Director, CAT Institute Seal w ith Address

CHECK LIST OF THE ENCLOSURES

ITEMS Please Darkenappropriate Box

Demand Draft (Examination fee)

Attested Photograph

Unattested Photograph

Attested copy of Mark sheet of Highest Qualification Obtained by theCandidate