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ONE YEAR PG CERTIFICATE PROGRAMME

APPLICATION FORM
NATIONAL PRODUCTIVITY COUNCIL For Office use only
Dr. AMBEDKAR INSTITUTE OF PRODUCTIVITY
No.6, (Old No.31-B) SIDCO INDUSTRIAL ESTATE Regn. No.
AMBATTUR, CHENNAI - 600 098
APPLICATION FOR PG PROGRAMME IN: DD No.
(1) INDUSTRIAL ENGINEERING □ Date :
(2) ENERGY MANAGEMENT □ Bank :
(3) ENVIRONMENT MANAGEMENT □ Branch :

Full Name :
Father's Name :
Date of Birth : Nationality :
Address for Communication:

Photograph
(Passport size)

Email ID : Tel No:


Mobile No.
EDUCATION (attested copies of certificates and mark sheets to be attached)
Graduate Engg. Course & Branch
Last 3 Years of Engg From - To Month & Year Maximum Marks
Remarks
Graduation (Month & Year) of Passing Marks Obtained

Second Year
Third Year
Fourth Year
Aggregate % in last three Years @ :
Post Graduate Course & Branch:
* If grades are awarded, documentary proof of conversion of grade to percentage should be provided
EXPERIENCE : (Attach attested copies. Project work during education not to be mentioned)
Name of Orgn &
Designation Nature of work From To Duration
Address

For any additional information attach separate sheets.


Examination Centres : Bangalore / Bhopal / Bhubaneswar / Kolkata / Chandigarh / Chennai / Delhi /
Gandhinagar / Guwahati / Hyderabad / Jaipur / Kanpur / Kalamassery / Mumbai / Patna
Centres will be finalised based on response. No expenses will be borne by NPC for appearing at the
Examination.
Centre Choise 1 2 3
Certified that the above information are true to best of my knowledge and I agree with all conditions
mentioned in Brochure.

Place

Date Signature

Application will not be considered unless attested copies of following certificates are attached

(Mark sheets of last 6 semesters in case of semester system)

For Office use only


Enclose the following certificate copies and tick appropriately Original (Verified
Copies
during Interview)

1. Graduate Engineering Degree Certificate □ □ □


2. Marksheets - 3rd & 4th Semester (2nd Year) □ □ □
Marksheets - 5th & 6th Semester (3rd Year) □ □ □
Mark Sheets - 7th & 8th Semester (4th Year) □ □ □
3. Post Graduation Certificate (if any) □ □ □
4. Date of Birth □ □ □
5. SC / ST / OBC Certificate □ □ □
6. Experience Certificate (if any) / N O C □ □ □

Signature Signature
NATIONAL PRODUCTIVITY COUNCIL HALL TICKET
Dr. AMBEDKAR INSTITUTE OF PRODUCTIVITY
Regn.No.
CHENNAI

Applicant's Name & Communicating address in Block Letters


(to be filled up by the applicant)

--------------------------------------------- ---------------------------------------------------
Signature of Candidate Check Signature
(to be put at the time of applying) (to be put at the time of Exam)

Please enclose a self-addressed stamped envelope (Rs.5/-) for mailing hall ticket

Written Examination on from 10.00 am to 1.00 pm

Centre Name and Address