10thNational Certification Examination for Energy Managers And Energy Auditors -July-2010
 ( Under the Energy Conservation Act, 2001 )
Supplementary Application Form

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Examination you are appearing for :            Energy Manager   Energy Auditor  
Registration  No.

Name of the Applicant*

(First Name)


(Middle Name)


(Surname)
Father's Name*
*Present Address Permanent Address
City *    PinCode *

City

 PinCode
State*

State
Date of Birth* 

Nationality
Indian

(Others Specify)
Community* GeneralSCSTOBC Sex
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    PinCode     
State
 
11. Total Work Experience Yrs Months
Examination appearing
Paper I Paper II Paper III
Paper IV
13.Examination Centre
a) 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:*
17.I agree to forward my name to any Training Agency conducting Preparatory Training Courses      
Yes No
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