[Online Course]

Application Form for Online Course Reg.No.: Not Alloted

Course Name Web Application using Apache, PHP & MySQL (Online Mode)
Course Start Date 17-May-2022 Course Fee 2200
Candidate's Name Priyanshu Kumawat
Father's Name Narendra Kumawat
Mother's Name: Sunita Kumawat
Date of Birth 03-Mar-2000 Aadhaar 748164262566
Category OBC Gender Male EWS No Ex-Serviceman No
Religion Hindu PH (Divyang) No Marital Status Single
Contact No 1: +91 8278655729 Contact No 2: --
Email ID: priyanshu332000@gmail.com
Correspondence Address:
433,surya nagar, Gopalpura bypass
District Jaipur Post Office Barkat Nagar Tehsil/Mandal Jaipur
State RAJASTHAN Country India Pincode 302015
Highest Qualification BE_BTech Status Appearing
Name of College / University Birla institute of technology mesra
Work Experience Details (If any) Designation: --
Name of the Organization : --
Fees Paid (In Rs.) Pending Date of Transaction NA
Reference No. (NIELIT) NA Transaction No.(PayU): NA
Payment Mode NA Bank Reference No. NA
Remarks
Declaration
I, Priyanshu Kumawat , hereby declare that, the above entries made by me are complete and are true to the best of my knowledge. These informations are based

on my certificates and records.I have read the course brochure carefully and I am fulfilling the minimum eligibility criteria for the course Web Application using

Apache, PHP & MySQL (Online Mode) .I understand that fees is non-refundable and I will not make any claim for any discount or refund of fee and security money

(if any).I will abide by all the rules and regulations of NIELIT Gorakhpur and shall follow all the pre-requisites for this course.I will not indulge my self in any

Mischievous Activity or in any behavior / act that may be constituted as ragging / harassment.I allow NIELIT Gorakhpur to send the updates on academic and

promotional activities through SMS and E-Mail.

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