14th National Certification Examination for Energy Managers And Energy Auditors-August-2013
( Under the Energy Conservation Act, 2001 )
Application Form


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Examination you are appearing for:            Energy Manager   Energy Auditor
Candidature:  Company Sponsored  Self-sponsored

1.Name of the Applicant*

(First Name)


(Middle Name)


(Surname)

2.Father's Name*
*3.Present Address 4.Permanent Address
City *    PinCode *

City

PinCode
State

State

5.Date of Birth* 

6.Nationality

Indian

(Others Specify)

7.Community* GeneralSCSTOBC 8.Sex
9.Employment Status Employed Self Employed Unemployed
10. Present Company Address 12. Contact Telephone. Fax, Email
Designation Office Phone
Company Name Fax
Res. Phone
Email*
Mobile
City Pin Code     
State
 
11. Total Work Experience Yrs Months
13.Examination Centre
Written Examination Centre
1. 2. 3.
     
14. Requisite Educational Qualification
Slno Name of Degree/ Diploma Subjects/ Branch Year of Passing(eg: 1988) Board / University
1.*
2.
3.
4.
15. Requisite Experience for fulfilling the eligibility criteria 
Slno Name of Employer/ Organisation Designation

Year

From

To

Nature of Work (Max 50 characters Only)
1.*
2.
3.
4.
5.
6.

16. DD.No.:* Amount (Rs.)*   Date:*
Bank Name:*

Declaration by the Candidate
I hereby declare that all the information given in the application form and enclosures are true to the best of my knowledge. I agree to the condition that if any information or any statement is found to be incorrect, my registration to the examination would be cancelled. I also understand that it is my responsibility to cross check information from the websites as mentioned in the prospectus for the allotted examination centre and issue of hall ticket. I shall inform NPC Chennai about any  change in my mailing address, telephone number and e-mail ID, if any, at the earliest. I also abide by the examination scheme and conditions as mentioned in the prospectus.
Place:
Date:
 * Mandatory