Institute of Good Manufacturing Practices India

Global accredited training & certification provider

REGISTRATION FORM

Programme: EXECUTIVE DIPLOMA IN FOOD MICROBIOLOGY

Mode: DISTANCE & E-LEARNING MODE

Please Note:
1. Please complete all the information accurately. Incomplete or false information may make
your candidature null and void.
2. The decision of the Institute will be final and binding on the applicants in all the matters
relating to registration. If the institute rejects any application, full refund will be made.
3. For details for the programme, please visit www.igmpiindia.org.
4. You are required to enclose soft (scanned) copies of all relevant testimonials along with the
registration form.

The completed registration form should be emailed and addressed to the Director, Institute of
Good Manufacturing Practices India (IGMPI), H-119, H Block Sector 63 Noida-201307 Delhi
National Capital Region (NCR) India to email ID info@igmpiindia.org.
Phone: +91 8130924488, +91 8587838177, +91 120-4375280

Application Details Affix a recent

Amount Rs.: 25000.00 coloured passport
Demand Draft/CHQ No.: size photograph
Dated:
Bank: STATE BANK OF INDIA
PayU/NEFT Reference no:

Registration Number

(Leave this space blank)

*Crossed DD or Cheque should be in favour of “Institute of Good Manufacturing Practices India”

payable at New Delhi. Please write your name and address at the back of DD/Cheque. Applicable
examination fee can be paid later as per the Institute’s examination notification.

PERSONAL INFORMATION

1. Full Name: Mohamed Mohzin Ghouse

2. Address of correspondence (in capital letters) 67 - SOUTH STREET, MUTHUPET,
THIRUTHURAIPOONDI TK, THIRUVARUR DT, TAMILNADU. Postal code/Zip code 614704
3. Mobile no.: 9659970024 / 7812861535
4. Date of Birth: 16/03/1981
5. Gender: MALE
6. Mother’s Name: RUKKIYA BEEVI
7. Father’s Name: GHOUSE
8. Email Id: GMMOHZIN@GMAIL.COM
9. Phone no with STD code.: No land phone
10. Nationality: INDIAN
11. Category: OBC
(SC: Scheduled Caste; ST: Scheduled Tribe; PH: Physically Handicapped; EWS: Economically
Weaker Sections; Ex-servicemen; Attached copy of the certificate as applicable for 10% fee
Concession)
WORK EXPERIENCE

12. Work Experience (If any)

i. Total work experience: Year Months
ii. List all your work

From To Total Name the Designation Brief job profile

completed organization
months

ACADEMIC QUALIFICATIONS

13. Pre-Bachelor’s Degree Examination(s):

Std. School/ Board/ Year % Marks Class/
Institute University completed Obtained Division
10th BISHOP HEBER HIGHER BOARD OF SECONDARY
1996 85% FIRST
High School SECONDARY SCHOOL EDUCATION, TAMILNADU
12th BISHOP HEBER HIGHER BOARD OF HIGHER SECONDARY
Intermediat 1998 76.58% FIRST
e
SECONDARY SCHOOL EXAMINATION, TAMILNADU

14. Bachelor’s Degree Examination(s):

DIPLOMA IN HOTEL
MANAGEMENT & Subject/Specializati Food & Beverage Production &
Degree Obtained
CATERING on Service
TECHNOLOGY
STATE INSTITUTE OF
HOTEL MANAGEMENT STATE BOARD OF TECHNICAL
College/Institute University
& CATERING EDUCATION AND TRAINING,
TECHNOLOGY TAMILNADU

Year Marks considered for award of Class/Division in Bachelor’s

From To
CGPA/ % of Marks obtained/ Grade
(DD/MM/YYYY) (DD/MM/YYYY)
 03/08/1998 17/04/2001 63% / FIRST CLASS

15. Post-Graduation Degree/Diploma (if any):

Degree Obtained N/A Subject/Specialization
N/A
College/Institute N/A University
N/A

Year Subject % of Marks obtained

From To
(DD/MM/YYYY) (DD/MM/YYYY) N/A N/A

N/A N/A

16. Professional qualification (if any):

Degree Obtained Subject/Specialization
N/A N/A
College/Institute University
N/A N/A

Year Subject % of Marks obtained

From To
(DD/MM/YYYY) (DD/MM/YYYY) N/A N/A

N/A N/A

DECLARATION

I have carefully filled up all the information and agree to abide by the decision of the Institute of
Good Manufacturing Practices India, New Delhi authorities regarding my registration. I certify that
the particulars given by me in the form are true to the best of my knowledge and belief.

Date: 06/12/2020
Place : Dubai, United Arab Emirates. Signed by (Mohamed Mohzin Ghouse)