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CCC Sample Form

1. Mr. Mohd Shahnawaz has applied for the CCC examination in December 2019 through the Madarsa Shamsul Uloom institute in Uttar Pradesh. 2. He provides his personal details including his name, father's name, date of birth, and contact information. 3. He declares that the information provided is true and agrees to abide by NIELIT's rules and regulations regarding the examination.

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Dilshad Ali Siddiqui
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110 views

CCC Sample Form

1. Mr. Mohd Shahnawaz has applied for the CCC examination in December 2019 through the Madarsa Shamsul Uloom institute in Uttar Pradesh. 2. He provides his personal details including his name, father's name, date of birth, and contact information. 3. He declares that the information provided is true and agrees to abide by NIELIT's rules and regulations regarding the examination.

Uploaded by

Dilshad Ali Siddiqui
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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19/10/2019 Certificate Examination Form

National Institute of Electronics and Information Technology


Ministry of Electronics and Information Technology, Government of India

Online Examination Application Form: Course on Computer Concepts(CCC)


Application Number Application Date & Time For Office Use Only

GOCCC6303107 19-Oct-2019 10:01:26 AM

1. Examination Details / पर ा का ववरण


Applied for Examination / कस पर ा के लए आवेदन कया CCC - December, 2019 (Every Month Exam Cycle )
Applied As / कसके प म आवेदन कया Institute State of Approved Institute / मा यता ा त Uttar Pradesh
सं थान के रा य का नाम
Centre Name of Approved Institute / मा यता 9901663 - Madarsa Shamsul Uloom,
ा त सं थान के क का नाम Sangaon Fatehpur
Examination Center1 / पर ाक 1 FTH -Fatehpur Examination Center2 / पर ाक 2 KAN -Kanpur
Appeared in Previous CCC Exam / पछल CCCपर ा No
2. Applicant's Personal Details / आवेदक का यि तगत ववरण
Applicant's full name / आवेदक का परू ा नाम Mr. Mohd Shahnawaz
Father's Name / पता का नाम Mr. Mohd Shamim
Mother's Name / माता का नाम Mrs. Taqdirun Nisha
Gender / लंग Male Category / वग General / सामा य
Disability / द यांगता No Disability Type / द यांगता कार Not Applicable
Date of Birth / ज म दनांक (dd-MMM-yyyy) 19-Oct-2003 Occupation / यवसाय Others / अ य
Aadhar Card Number / आधार काड सं या N/A
3. Contact Details / संपक ववरण
Phone with STD code / दरू भाष एस ट डी कोड स हत Mobile Number / मोबाइल नंबर 9598545194
Email Address / ईमेल पता [email protected]
4. Address Details / पता ववरण
Address Line1/पता पंि त 1 Village Sangaon
Address Line2/पता पंि त 2 Post Sangaon
Address Line3/पता पंि त 3
City Name/शहर का नाम Fatehpur District / िजला Fatehpur
State / रा य Uttar Pradesh Pin Code / पन कोड 212601
5. Educational / Qualification Details / शै क / यो यता का ववरण
Highest Educational Qualification / उ चतम शै क यो यता 10Th Pass
Year of Passing / उ तीण वष 2018
6. Declaration / घोषणा
I son of Smt Taqdirun Nisha and Shri Mohd Shamim hereby declare, that, the particulars submitted by me in the online examination application form of CCC are true to the best
of my knowledge and belief. I agree to abide by the rules and regulations of NIELIT and also to the decision of NIELIT regarding my admission for the examination. I have noted that,
NIELIT has the right to withhold my result even after my appearing in the examination in addition to any other action as may be deemed fit in the event of any of the
statements/particulars made above being found incorrect. I have noted that, I might be required to appear in the examination at any other examination centre not specified under
examination centre choice column (1). I further understand that, in the event of non-conduction / non-evaluation of my examination due to any reason whatsoever, I will not held
NIELIT responsible for any damages.
म, ीमती Taqdirun Nisha और ी Mohd Shamim का पु यह घोषणा करता हूँ क सीसीसी पर ा हे तु ऑनलाइन आवेदन फाम म मेरे वारा व णत सम त जानकार मेरे ान और व वास से स य है । म
रा.इ.स.ू ौ.सं. के नयम व व नयम तथा मेर पर ा हे तु वेश से संबं धत रा.इ.स.ू ौ.सं. के नणय से भी सहमत हूँ। मझ
ु े ात है क रा.इ.स.ू ौ.सं. को उपयु त उि ल खत कसी भी कार का कथन/ ववरण अस य
पाये जाने पर पर ा म मेर उपि थ त के प चात भी मेरा प रणाम रोके जाने के अ त र त अ य कोई कारवाई जो उ चत समझी जाए, अ धकार है । मझ ु े ात है क मेर पर ा क चयन कॉलम(1) के अंतगत कसी
भी अ य पर ा क म करायी जा सकती है । आगे, म यह भी समझता हूँ क कसी भी कार के कारणवश मेर पर ा के अ नधारण/अवमू यांकन क ि थ त म, मेर कसी कार क त के लए
रा.इ.स.ू ौ.सं.उ तरदायी नह ं होगा।
7. Payment Detail
Fee Details: Exam Fee: 590.00 [Five Hundred Ninety Rupees Only]
Payment Mode: Not Paid Payment Transaction No./भग
ु तान सं या Not Paid
Submission of examination form is 31-Oct-2019 and Last date of fee payment is 31-Oct-2019 .
Note * Please deposit fee / submit (as applicable) for exam form at the following Address till last date / अं तम तार ख तक कृपया न न पते पर शु क / पर ा फाम (जो लागू हो) जमा कर:-
Approved Centre Name:- Madarsa Shamsul Uloom , MADARSA SHAMSUL ULOOM UNDER SHAMSUL ULOOM EDUCATION SOCIETY , SANGAON FATEHPUR SANGAON
FATEHPUR ( Uttar Pradesh )
Pin Code / ( पन कोड): 212601, Phone Number / (फोन नंबर) : NA

Left hand thumb impression / बाएं हाथ के अंगूठे का नशान Signature of Applicant/ ह ता र
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