MSME TECHNOLOGY CENTRE Bengaluru Ministry of MSME, Govt. of India Plot No 6, Aerospace Park, KIADB Industrial Estate, Devanahalli, Bengaluru - North CUTEST R ae wT (Note: All te entries (o be filled in English & CAPITAL letters only) Form No.: Roll No.: [ ‘Year. ‘Months Paste Course Code: Duration: LJ Se Course Name: 35 mm x 35 mm. Course Commencing From: Name: Father's Name: ane Address: Contact Details ph. || | | | | i | Date of Birth: I fin tmaaen CO YE KR Sex: wo FO Blood Group: Gaste Category :sc |_| ST) OBC) OTHER (1) Religion: = =I “A aprepral® 8299) wNORITY [| GENERAL |) Occupation of Father: : _______] Income Per Annum: Rs.[ Details of Education Qualification: (Attach the copies of certificate of verification) Start with Matriculation: % of Marks _ Year of Passing Other Courses Experience: Registration Fee: Cash/D. D. Rs. ,IFD. D. give details . (Non Refundable) —_ Rs. DD.No.| —SsCate: DECLARATION | hereby solemnly dectare thatthe information furnished by mein this aplication is rue tothe best af my knowledge and belief. | abide the rules & regulation, ‘general information given the prospectus and enforcedby the institute from time fo time. If any information found incorrect at any stage of my study, the nsttute Feserves its right fo cancel my registration’ admission and no fees shall be refunded to me Place: Date: Signature of Appcant RECEIPT Received with thanks from Mr/Mrs /Ms an amount of (Rs ) as cost of Admission form No. towards registration for the training Course No, course Date: Head (Training)FOR OFFICE USE ONL’ APPROVAL FOR ADMISSION Course Commencing From: | = Course Fee (Basic): Rs. ——— aes ‘Admission Cadre Regular @ponsored = [2] MeMe TreineellEl= MEME Enmlovee ==: = Groupe] RSE ae Cont. Edn.(_] Engg. Student | |Category | |MSME Employee's Child (] Others (1) Cadre Details: —— = = ee Fees to be paid Registration Fee: alate Course Fee: YesL] Nol] — ifYesRs. a Other Fee(|f any): YesL] No [1] IfYes Rs Any other comments/ suggestion, STATUS OF ADMISSION RollNo: | | | | | Details of Course Fee Payment : Description Total Amount Fee Dues (Remarks): HEAD OF DEPT.(TRG.) COURSE CO-ORDINATOR