Cheminformatic Institute of Science Studies Lucknow

4/488, Ground Floor Vibhav Khand, Gomtinagar, Lucknow-226010, (U.P.) INDIA

Tele:-0522 - 430 64 64 Mob : 09554064000, 09559196700
Website: www.cisstudies.in E-mail: info@cisstudies.in

Application Form
Paste your
self attested
photograph
Participation No. ____________________________
(For office use only)

All columns are compulsory, No column should be left blank, All in block letters

1. Candidate’s Name* ___________________________________ ____________________________________

(First) (Last)

2. Father's / Husband’s Name* ___________________________________________________________________________

3. Date of Birth*
(D D M M Y Y Y Y)

4. Gender Male Female

5. Address for Correspondence* ___________________________________________________________________________

___________________________________________________________________________
City ____________________ State ____________________ Pin ______________________
Country ___________________________ Nationality________________________________
6. Telephone No. (if any)* Code __________ (O) ______________ (R) ______________(M)______________________
7. E-mail* ___________________________________________________________________________

8. Academic Qualifications*
College/Institute Trade/Branch Year Result with Percentage

9. Project
Name of Project Platform Duration in Days

Payment Details:
10.Crossed Cheque / Demand Draft No. __________ dated________ Drawn on ____________________ for Rs. ____________________
(Bank draft must be drawn in favour of "CIS Studies Lucknow” payable at Lucknowi. Candidates are advised to write their name
and address at the back
of demand draft)
* for online payment details please call or mail us on the given addresses:
Mob.: 0954064000

*Only at par / Multicity cheque will be accepted

11Documents to be attached with application form:
i) Fee DD/ Cheque ii) Photocopies of Last Academic Qualification with self attested
iii) 2 Copies of Passport size photograph one pasted and one pinned
Note: At par Cheque only accepted.

*Mandatory to fill

Date :

Place :
(SIGNATURE OF THE PARTICIPANT)