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APPLICATION FORM
Testing Mechanical
Testing Chemical
Computer Training
Computer Aided
Engineering
PLC Robotics
Electrical
Incubation
Refrigeration & AC
Training
Design
Assistant Manager
(Finance & Accounts)
Please copy the tick mark symbol and paste it wherever needed in the Application Form.
NOTE: Fields Marked * are Mandatory. In Case Mandatory fields are not filled, the Application
Form will be rejected.
A) PERSONAL DETAILS
1.
Name Of Applicant*
(in BLOCK letters)
Fathers/Mothers Name*
AMRITANSHU MISHRA
13-12-1984
4.
Date Of Birth*
(dd/mm/yyyy)
Aadhaar No.
5.
Category*
General
2.
3.
SC
ST
OBC
Yes
No
7.
Whether belongs to
Person with Disability
Category *
Gender*
8.
Marital Status
Married
6.
9.
Whether belongs to
Minority Community*
10. E-mail*
11. Mobile*
12. Complete Current
Residential Address
Male
Female
Yes
eemishra@gmail.com
9839883322
House No.
Street Name
City
District*
State*
Pin code*
House No.
Transgender
Single
No
Street Name
City
District*
State*
Pin Code*
Gopiganj
Sant Ravidas Nagar, Bhadohi
Uttar Pradesh
221303
Name of
Examination / Degree
passed
(No abbreviation to be
used)
Full
Name
of Duration Date of Regular/ %age
Board/University/Institut (Only in passing Distance/
e (No abbreviation to be years)
Part-time
used)
(Class 10th)
All
India
School
School
Certificate
Examinations
Senior Central
Board
Of Allahabad
Technology
, Institute
Of
Biotechnology
25-05-
Regular 63.6
2002
Agriculture
Regular 73
2000
Examination
Bachelor
07-05-
Deemed
07-09-
Regular 68.9
2007
University
4
C) Post-Graduation Diploma / Masters Degree*{Including CA / ICWA (CMA) / CA (Inter) /
ICWA(CMA)(Inter), as the case may be}
#
%age
Jaipuriya
56.62
Diploma In
Institute Of
Management
Management,
Master of
Marketing
Lucknow
Shobhit
Business
Management
University
12-05-
Regular
2011
24-09-
Distance 61.78
2014
Learning
Administration
3
4
D) EXPERIENCE* (Starting from the present employer) {In case of CA / ICWA(CMA) / CA(Inter) /
ICWA(CMA)(Inter), as the case may be, Article-ship / Practical Training may be shown as experience}
#
Full Name of
Employer (No
Abbreviation to be
used)
Centum Learning
Designation
Duration
DD/MM/YYYY
From
To
Admin
25-11-
Centre Varanasi
Manager
2013
Present
Job profile
(Maximum 30
words)
Looking after Admin
duties, admissions,
Marketing,
Gross
Salary
(Per
month)
20,000
Promotion, Sales,
purchasing,
maintenance, hiring
2
Reliance Retail
Assistant
12-02-
15-11-
Limited
Manager -
2013
2013
management and
Operations
20,000
Managemen
04-07-
05-04-
Training
Looking after
t Trainee
2011
2012
fashion section.
28,210
Managing Floor,
Marketing activities,
Team Management,
4
Pandey Nursing
Admin
01-07-
01-07-
Home, Gopiganj
Manager
2007
2009
operations of the
16000
hospital, marketing
and promotions of
the hospital in
nearby areas.
5
E) ADDITIONAL QUALIFICATION / TRAINING ATTENDED (of more than 3 months duration), if any
#
1
2
3
4
5
Duration
(In months /
years)
Brief Description
(Maximum 30 words)
Yes
Permanent
Contract
No
Address __________________________________________________
__________________________________________________________
Phone No. _________________________
G) HAVE YOU EVER APPEARED IN INTERVIEW FOR ANY POST IN NSIC DURING LAST 3 YEARS*?
If Yes, Please mention the name of the Post and Year of Interview
Yes
No
Post _________________________________________________________
Year _______________________________________________________
H) PAYMENT DETAILS*
Demand Draft
Number
Date
Amount
(in Rs.)
_______________________
Signature of the Applicant*