Form No.

: ________
SIEMENS CENTER OF EXCELLENCE
APPLICATION / ADMISSION FORM

Date: ____/____/____

Note: Fill the form in BLOCK letters and use Black ink only

Personal Details

Name
(First Name) (Middle Name) (Last Name)
Present
Address
Permanent
Address
Contact Emergency Contact
Number Number

Email Id

Educational Profile
Name of University Degree and Year/Sem of Any Backlog CPI/Aggregate
College ID
and College Branch Study (Y/N) Marks (%)

Course Selected
Sr
Name of the Course Course Code Duration Slot Applied
No

1
DSL/COE/LDCE/F/04/01
Terms and Conditions:

1. Certificates shall be issued after successful completion of the training and assessment.
2. Students must attend the training as per the time slots allotted.
3. Every student has to sign the Training History Card daily as per assignment given.
4. In case of inconsistency in attendance, improper discipline, breaking rules & regulations, SIEMENS
Center of Excellence shall have the right to terminate the training at any point of time and the
student may be suspended from enrolling into the other courses in future.
5. Discontinuance of course for few days will be permitted with prior written request from Student
and approval by Faculty member.

I hereby agree to the above terms & conditions set by SIEMENS Center of Excellence.

________________
Student Signature

Below documents to be submitted along with admission form:

1. Two Passport size photograph
2. Address Proof: “Driving License / Passport / Election card / Aadhaar Card”
3. Latest Educational Certificates
4. College ID

------------------------------------------------------------For Office use only---------------------------------------------------

Admission has been approved / Rejected

Name Designation College Seal

Signature Date

Note: For all the enrolments, Student needs to fill the Enrolment form and get the same approved
from the Authorized Representative of the college. Only the College Authorized representative
approved candidates will be enrolled for the courses.

Remarks (if any) by Center Head:

•
•
•
•
____________________
Centre Head Signature

2
DSL/COE/LDCE/F/04/01