05 Nist Registration Form_cochin.pdf

APPLICATION FORM

Please fill in the required details for registra on along with 2 passport size photographs. Please write or type clearly: Please Tick (√) in the appropriate: PERSONAL INFORMATION Title (Please Select in the appropriate column)

Mrs

Mr

Miss

Dr

Others

✔ Given Name (As Per Id Proof )

DILSHAD

Surname (As Per Id Proof )

THEYYAPARAKKAL KASIM

House Number :

Street Name & Address:

KALLUVEETTIL(H) UNNIKULAM POST

POONOOR City:

Country :

THAMARASSERRY INDIA

Postal Code:

Country of Residence :

673574

INDIA

Date of Birth: (DD / MM / YY)

Gender: Please Tick (√)

Na onality:

Passport Number :

. 07/06/1993

✔ Male

INDIAN

P1504807

Landline:

Female Mobile Number:

Official Number:

9633022447 Emergency Contact Number:

E-Mail_ID:

[email protected]

SPECIAL NEEDS OF CANDIDATES If “YES”(√) provide appropriate Proof If “NO”(√) men on “Not Applicable” Do you have any permanent or long term disabili es or temporary disability in performing certain types of work? ✔ YES NO Do you have any medical condi on or specific learning need?

Please Specify:

Please Specify: ✔ YES NO Is English your second language? What is your first language?

Please Specify: malayalam ✔

Page 1 of 4

YES

NO

Express House, Indian Express Building,Banerji Road, Kaloor, Ernakulam - 682 017. Website: www.nistinstitute.com E-Mail: [email protected] Tele: +91 48 44013005, +91 48 44013006

Vizag Delhi Cochin Mumbai Bangalore Chennai 044 45643333 080 40903860 0484 4013005 022 29207744 011 40666100 0891 6662644

Kolkata 033 40708101

F/MK/01

Pune Navi Mumbai Vadodara Hyderabad 040 66689777 020 65247999 022 62397088 026 52343437

APPLICATION FORM

INFORMATION PRESENT EMPLOYMENT(Name of the Company)

al khater & al naimi

DESIGNATION

electrical maintenance

TOTAL YEARS OF EXPERIENCE

3

OTHER HEALTH & SAFETY QUALIFICATION

NIL

ACADEMIC QUALIFICATION

B.TECH ELECTRICAL

NAME OF THE COLLEGE

UNIVERSITY OF CALICUT

MONTH OF COURSE JOINING

5/2012

SELF SPONSORED (Yes/No)

yes

SPONSORING COMPANY (Name of Company & Address to be mentioned)

OUR PRODUCTS Please select the courses you are applying for DATE:

MANAGING SAFELY

IOSH

✔

NEBOSH

IOGC

TRAINING DATE:

TRAINING DATE:

British Safety Council

HSW

INT GENERAL CERTIFICATE (IGC)

RISK ASSESSMENT

FIRE SAFETY

DATE:

DATE:

TRAINING DATE:

COURSE MODE(√) E-LEARNING

CLASSROOM TRANING

✔

Page 2 of 4

Express House, Indian Express Building,Banerji Road, Kaloor, Ernakulam - 682 017. Website: www.nistinstitute.com E-Mail: [email protected] Tele: +91 48 44013005, +91 48 44013006

Vizag Delhi Cochin Mumbai Bangalore Chennai 044 45643333 080 40903860 0484 4013005 022 29207744 011 40666100 0891 6662644

Kolkata 033 40708101

F/MK/01

Pune Navi Mumbai Vadodara Hyderabad 040 66689777 020 65247999 022 62397088 026 52343437

APPLICATION FORM How do you know about NIST? Website

Google Search

Mail

Reference

Adver sments

✔

SMS Exhibi ons

Facebook

If Others Pl men on:

EXAMINATION DETAILS (NEBOSH HSW ONLY) Please indicate the unit examina on/s for which you are registering. *Please Tick (√)+ HSW1

EXAM DATE:

HSW2

EXAM DATE:

EXAMINATION DETAILS (NEBOSH IGC ONLY) Please indicate the unit examina on/s for which you are registering. *Please Tick (√)+

✔ IGC1

EXAM DATE: 4th

GC 2

april

EXAM DATE: 5th

april

GC 3

EXAM DATE:

EXAMINATION DETAILS (NEBOSH IOGC ONLY) Please indicate the unit examina on/s for which you are registering. *Please Tick (√)+ IOG

EXAM DATE:

TO BE FILLED BY NEBOSH IGC, HSW & IOGC RE-SIT CANDIDATE ONLY (Mandatory if you a end or register with NEBOSH through any course provider) Course Provider

Student Number

Date/s of Previous Si ng

Please ck the appropriate ID proof to be enclosed (√)

✔

Passport Copy

Driving License

Others

Please Specify:

Payment Mode: (Please ck the appropriate box) Cheque Payment Details:

✔ Online Transfer

DD

Cash

Student Loan

Cheque/DD shall be provided in the name of NIST Ins tute Private Limited. Online transfer could be done to any of the bank accounts given below.

Express House, Indian Express Building,Banerji Road, Kaloor, Ernakulam - 682 017. Page 3 of 4

Website: www.nistinstitute.com E-Mail: [email protected] Tele: +91 48 44013005, +91 48 44013006

Vizag Delhi Cochin Mumbai Bangalore Chennai 044 45643333 080 40903860 0484 4013005 022 29207744 011 40666100 0891 6662644

Kolkata 033 40708101

F/MK/01

Pune Navi Mumbai Vadodara Hyderabad 040 66689777 020 65247999 022 62397088 026 52343437

APPLICATION FORM BANK DETAILS

Payment Mode: Online Transfer / Direct Cash Deposit / DD / Cheque Account Name: NIST Ins tute Private Limited Bank

Loca on

Account Number

Account address

SWIFT CODE

Account IFSC CODE

HDFC

KALOOR, KOCHI

12862560000095

HDFC Bank Ltd., Metelda, Kaloor – Kadavanthra Road, Kaloor – 682017, Kochi

HDFC0001512

HDFCINBBCOC

SBI

Abhiramipuram

32609222030

SBI bank, New No.4, First Street, Abhiramipuram, Chennai - 18.

SBIN0012749

SBININBB

TERMS AND CONDITIONS: Ø Ø Ø Ø Ø Ø Ø Ø

Ø Ø

Prior registra on is required as there are only limited seats. Registra on forms, copy of passport, passport size photos should be submi ed on or before the last date of every batch. Cancella on should be confirmed in mail as scanned copy duly signed by the candidate or as a hard copy. Course cancella on or batch transfer requested on or a er the registered batch closing date, payment will not be refunded at any cost. Cancella on made prior to the commencement of training will be deducted 15% (admin cost) of the total course fee. Candidate discon nued during the training will not be refunded at any cost and they are subjected to pay the agreed amount. Any change in schedule must be informed before 4 weeks to the commencement of training to our ins tute either by e -mail or as a hardcopy duly signed by the candidate. NIST Ins tute Private Limited will cancel the training due to unavoidable situa on. However, we will bring the rescheduled course to delegates’ no ce in much advance without any addi onal charges and if necessary we have rights to change the tutor for any cri cal situa on. Any cancella on made by the company will be refunded without any deduc on. For any cancel la on or batch transfer we will communicate 1 week prior to the closing date. Payments should be made only to NIST Bank Account Details. NIST is not responsible if the payment is done to any individual account.

I declare that the informa on herein is true and correct to the best of my knowledge, I accept the Terms and Condi ons within the applica on document and I understand that this applica on is subject to approval by NIST. Signature:

Date:

OFFICE USE ONLY Month of joining: ___________________________________________________________________________________________ Approved by :____________________________

Page 4 of 4

Date:______________________________________________

Express House, Indian Express Building,Banerji Road, Kaloor, Ernakulam - 682 017. Website: www.nistinstitute.com E-Mail: [email protected] Tele: +91 48 44013005, +91 48 44013006

Vizag Delhi Cochin Mumbai Bangalore Chennai 044 45643333 080 40903860 0484 4013005 022 29207744 011 40666100 0891 6662644

Kolkata 033 40708101

F/MK/01

Pune Navi Mumbai Vadodara Hyderabad 040 66689777 020 65247999 022 62397088 026 52343437