Institute of
Cheminformatics Studies
Admission cum Registration Form for Distance Education
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NO COLUMN SHOULD BE LEFT BLANK (ALL IN BLOCK LETTERS)

Course applied for: Post Graduate Diploma in .................................

1. Name of the Candidate _______________________________
2. Date of Birth _______________________________
3. Nationality _______________________________
4. Address for Communication _______________________________
    _______________________________
  City _______________________________
  State ______________________________ Pin ____________________________
  Tel.: _______________________________ Mob: __________________________
  E-mail: ____________________________ E-mail: ________________________
5. Particulars regarding higher education:
 

Exam / Degree / Diploma

University / Institute

Major Subjects

Year

       
       
       
       
       
       
6. Employment Information (last three):
 

Name of Employer

Nature of Employment / Work

Worked

Designation

From

To
         
         
         
         
         
         
7. Any additional qualification such as membership of scientific society etc.
  _______________________________________________________________________________________
  _______________________________________________________________________________________
8. Crossed Demand Draft No.____________dated__________Drawn on__________________ for Rs._____________
  (Bank draft must be drawn in favour of Institute of Cheminformatics Studies.Candidates are advised to write their name and address at the back of demand draft
9. Details of Payment :
 
(i) Course Fee _____________________
(ii) Examination Fee _____________________
(iii) Total Fee _____________________
10. Documents to be attached with application form:
 
(i) Total Fee Draft
(ii) Certificates & Detailed marksheet of the qualifying examination.
(iii) Two passport size photographs.
(iv) Valid proof of SC / ST / OBC / Govt Employee / Physically handicap for fee concession should be enclosed with the application form.
11. References:
 
(a) Name: _________________________________________
  Designation: _________________________________________
  City: _________________________________________
  State: _____________________ Pin: _____________________
  Tel.: _____________________ E-mail: _____________________
(b) Name: _________________________________________
  Designation: _________________________________________
  City: _________________________________________
  State: _____________________ Pin: _____________________
  Tel.: _____________________ E-mail: _____________________
(c) Name: _________________________________________
  Designation: _________________________________________
  City: _________________________________________
  State: _____________________ Pin: _____________________
  Tel.: _____________________ E-mail: _____________________

DECLARATION

I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found false or incorrect or suppressed, my candidature at any stage, is liable to be cancelled / terminated.
Date : _____________ (SIGNATURE OF THE APPLICANT)
Place : _____________

Downloaded Forms should accompany Demand draft of Rs. 250/- as application fee along with the course fee.

Send the Complete Application form at the Address Given Below :

Institute of Cheminformatics Studies
C-56 A/28, Sector - 62, Noida - 201 301
INDIA
Tel : 0120 - 3947413
Mob : 09810535368, 09818473366

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