www.iactglobal.

in
Application Form for Certification Programmes of CEP, IIT
Delhi
(Email the filled application form to registration@iactglobal.in ONLY.
Forms sent to any other email id will not be accepted)
(Fields marked with * are mandatory & Form should be filled in block
letters. Only black/blue ink)
Course Name*: ____________________________________________________
PERSONAL DETAILS of CANDIDATE
Photograph

Name* __________________________________________________________
Fathers Name*: __________________________________________________

Date Of Birth (dd/mm/yy)*: ______________________ Gender*: ___________

E-mail Id* ________________________________________________________
Educational qualification (attach Photocopy of Degree/Final Year
Marksheet)*:Graduation degree

University

Year of Passing

Additional Qualification (if any):

Postal Address*:
____________________________________________________________________
______________________________________________ Pin/Zip Code:
________________________

Phone (Home): _______________________________ Mobile:

______________________________
PROFESSIONAL DETAILS (If Employed)
Name of the Company:
_____________________________________________________________

Present Designation:
______________________________________________________________________

Total Work Experience:

_____________________________________________________________

Signature of Candidate
Date

% of Marks

www.iactglobal.in
Address (Work):
___________________________________________________________________

Phone (Work):
____________________________________________________________________
I hereby declare that the information provided herein is correct to the best of my
knowledge and belief. Moreover, I agree to the terms and conditions
(http://iactglobal.in/terms-conditions.asp) of IACT Global. I shall complete the programme within the
duration of 3 months.

Signature of Candidate
Date