SIMLAPAL YOUTH COMPUTER TRAINING

CENTRE
A joint Initiative of DEPARTMENT OF YOUTH SERVICES
GOVT. OF WEST BENGAL
Raipur * (Jhargram Road) * Bankura
Telephone: 03243-267054
ENROLMENT FORM
For Office Use Only

Affix
Your Selfsigned
Latest
Passport-sized
Photograph

Course Name & Session :

Admission Bill No. & Date :
Studentship No. Allotted :

Name (In Block

Letters Only):
Fathers
Name:
Mailing address:

.
Pin Code:

Sub Division/Block: .P.S:

Tel. No. (If any)Employed/Un-employed/Student:

..
Date of Birth: .. (As per admit card)
Any previous knowledge on Computer? Yes/No
Course opted for (Mention the Course Name of your selection)
..
Whether old student: Yes/No, Lateral Entry To

If Yes, Mention previous Course Name & Studentship No

.
Educational Qualification (Xerox/Photocopies of Mark sheets and Admit Cards
should be attached)
Exam. Passed/Appeared
with year

Name of Board/University

Percentage of Marks

I do hereby unequivocally declare that the all the particulars furnished above are true to the best of my knowledge and
belief. I also declare that I will strictly abide by the rules and regulations of Youth Computer Training Centre as described on the
back page. Any violation of such rules will invite termination of my training from this computer centre.

(Fathers/Guardians Full Signature)

(Applicants Full Signature)
Date:
Please See Overleaf

Date: