CENTER FOR HEALTH SAFETY AND ENVIRONMENT

APPLICATION FORM

Title: First Name: Middle Name:

Last Name: DOB: Age / Gender
Email Id:
Contact No:
COMMUNICATION ADDRESS PROGRAM ENROLLED IN (Tick (√/x)) Photo
1. PG Diploma in Occupational Health safety and environment
2. Advance Diploma in Industrial safety
3. Others specify: _________________________________

EDUCATIONAL QUALIFICATIONS PROFESSIONAL QUALIFICATIONS

1. 1.

2. 2.

CAREER RECITAL (Mention current employer details) Years of Experience:

COMPANY NAME PROJECT NAME CLIENT LOCATION DESIGNATION

1.

PAYMENT OPTIONS
1. Payment(s) can be transferred through Internet Banking or Cash Deposit at AXIS BANK.
2. Account details:

Name: CENTER FOR HEALTH SAFETY & ENVIRONMENT

Account number: 916020035794057
Bank : Axis Bank, Nizampet village
IFSCode: UTIB0002960

3. Opt for One time Payment / Two months / Three Months instalments.
4. Once the payment is done, it is the responsibility of the user to confirm the same.
5. INVOICE along with other communications will be sent by post/ by hand, once full payment is received.
Declaration:
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to
inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or
misrepresenting, I am aware that I may be held liable for it. I hereby authorize sharing this information with CENTER FOR HEALTH SAFETY
AND ENVIRONMENT & its entities.
Note: Kindly submit a photocopy of your highest educational certificate and documents supporting you current employer payslips,
experience certificate, employer recommendation letter, offer letter with this application form. Mention a minimum of two contact
numbers.
By signing this document, I have read, understood and accept Terms and Conditions of CENTER FOR HEALTH SAFETY &
ENVIRONMENT for the access of training program.
Signature:_________________

Date:_____________________

FOR OFFICIAL PURPOSE ONLY

Application ref no Class Start Date Exam applied on
Class End Date Exam date
Payment received Payment invoice no Invoice given (Y/N)
Certificate no Certificate received on Certificate issued on

Signature & Seal of official with date:_______________________