310, 3rd floor , Lalbhai Contractor Complex,

Opp. Nanpura Library Nanpura, Surat.

P H O T O
1. APPLICATION FOR

2. SPECIALIZATION

3. NAME OF STUDENT(SURNAME/FIRST NAME/MIDDLE NAME)

4. FATHER’S/HUSBAND NAME(SURNAME/FIRST NAME/MIDDLE NAME)

5. DATE OF BIRTH(DD/MM/YYY)

6. MALE FEMALE 6A. MARRIED UNMARRIED

7. ADDRESS FOR CORRESPONDENCE

8. PERMANENT ADDRESS

9. CONTACT NUMBER
(R) (O) (M)
10. EMAIL ID

11. ACADEMIC DETAILS

Sr. No. Course Name of the Institution Pass Year Result

12. WORK EXPERIENCE

Sr. No. Name of the company Position No of years

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 310, 3rd floor , Lalbhai Contractor Complex,
Opp. Nanpura Library Nanpura, Surat.

P H O T O

13. DETAIL OF FEES PAID

Cash Cheque Demand Draft Credit Card
Payment Detail

Declaration by the candidate:

I certify that all the information provided in this application form is complete and accurate. I agree to all the rules
and regulations of the program set from by PIMT and abide by them. I would strive to uphold the standards of
the organization.

Signature Da te

Documents to be submitted :
1. Photo copies of Mark sheets and Certificates
2. Six Photographs
3. Residence proof
4. ID proof
5. Work experience letter

(Please note that fees once paid is not refundable under any cirumstances)

For office use only

1. Enrollment No.
2. Name of Counsellor
3. Centre Head