Select the Course

Name in Full (As per SSC / X Certificates):

Gender:          Male Female
Nationality:
Date of Birth:
Place of Birth:
State:
Country:
Mother's Name:
Father/Husband's Name:
Current Address:

PIN:

City:

State:

Country:

Permanent Address same as above?

Permanent Address:

PIN:

City:

State:

Country:

Phone No. with STD Code:
Mobile No.:
Applicant's E-mail:
Applying for Center at:
Examination Examination Authority Year Marks/Grade Obtained Max. Marks Awaited/Passed
X Min. Qualification for registration
XII


Place:
I hereby declare that the information furnished herein above is true to the best of my knowledge.